THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 
MRS.  PRUDENCE  W.  KOFOID 


V  ••  <  \  V 


Y 


\% 


ON 


MINOR    SURGERY. 


F.  W.   SARGENT,   M.D., 

MEMBEE  OF  THE  COLLEGE  OP  PHYSICIANS  OP  PHILADELPHIA;   ONE  OF  THE  SURGEONS 
TO  WILLS'  HOSPITAL,  ETC.  ETC. 


NEW  EDITION,  REVISED  AND  ENLARGED. 

WITH 

ONE  HUNDRED  AND  EIGHTY-  ONE  ILLUSTRATIONS. 


PHILADELPHIA: 
BLANCHARD    AND    LEA. 

1856. 


\ 

\v 


Entered,  according  to  Act  of  Congress,  in  the  year  1855,  by 
BLANCHARD   &   LEA, 

in  the  Clerk's  Office  of  the  District  Court  of  the  United  States  in  and  for  the 
Eastern  District  of  Pennsylvania. 

Printed  by  T.  K.  &  P.  G.  Collins. 


TO 

GEORGE  W.  NORRIS,  M.  D., 

SURGEON   TO    THE    PENNSYLVANIA   HOSPITAL, 

AS  A  TRIBUTE  OF  RESPECT 
FOR  HIS  PROFESSIONAL  AND  PERSONAL  CHARACTER, 

AND   IN   ACKNOWLEDGEMENT 
OF   HIS   INSTRUCTIONS    AND   REPEATED   KINDNESS, 


IS  INSCRIBED 

BY  THE  AUTHOR. 
1*  (T) 

M3518S7 


PREFACE  TO  THE  NEW  EDITION 


THE  very  kind  manner  in  which  the  first  edition  of  this 
little  book  was  received,  has  stimulated  the  Author  to  renewed 
diligence  in  adding  to  it  whatever  seemed  to  him  calculated 
to  augment  its  usefulness  and  its  comprehensiveness.  He 
hopes  that  his  efforts  will  be  found  successful. 

By  an  increase  in  the  size  of  the  page,  it  will  be  seen  that 
the  considerable  additions  to  this  edition  have  been  introduced 
without  causing  any  enlargement  of  the  volume. 


(vii) 


PREFACE. 


THE  object  which  the  Author  has  had  in  view  in  the  pre- 
paration of  the  following  pages,  has  been,  to  present  to  the 
younger  surgeon,  and  to  the  student,  information  relative  to 
the  art  of  bandaging,  and  to  some  other  points  of  importance 
in  the  practice  of  surgery.  These  are  subjects  which  are  but 
slightly  alluded  to  in  systematic  courses  of  lectures,  or  in  most 
of  the  published  treatises  on  the  science ;  yet  the  necessity  of 
a  familiar  acquaintance  with  them  will  be  readily  acknowledged 
by  every  surgeon  of  experience. 

In  the  collection  of  the  materials  for  this  volume,  the  Au- 
thor has  availed  himself  very  freely  of  the  knowledge  of 
others,  as  exhibited  in  books,  and  of  his  own  opportunities  in 
hospitals  and  in  private,  of  gaming  practical  acquaintance 
with  the  subjects  of  which  he  has  treated.  He  trusts  that  he 
has  not  failed  in  his  intention,  always  to  give  due  credit  to 
all  from  whom  he  has  taken  information.  Originality  can 
scarcely  be  expected,  in  a  work  of  this  kind,  excepting,  per- 
haps, in  its  composition. 

The  book  is  divided  into  five  parts.  Of  these,  the  first  em- 
braces a  description  of  the  implements,  if  such  a  term  be  ad- 
missible, with  which  the  ordinary  duties  of  the  surgeon  are 
accomplished. 

The  second  treats  of  the  composition  and  preparation  of 
Bandages,  of  their  application  to  the  different  regions  of  the 


X  PREFACE. 

body,  and  of  the  purposes  which  they  are  thus  made  to  sub- 
serve. 

The  third  is  devoted  to  the  consideration  of  the  apparatus 
of  various  kinds,  used  in  the  treatment  of  Fractures.  In  the 
arrangement  of  this  portion  of  the  volume,  the  Author  has 
thought  it  expedient  to  give  pretty  full  details,  showing  the 
indications  of  treatment  in  each  particular  case  of  Fracture, 
and  thereby  rendering  more  manifest  the  adaptation  of  each 
bandage,  splint,  or  other  dressing,  to  the  fulfilment  of  these 
requirements. 

The  fourth  division  describes  the  mechanical  means  em- 
ployed in  the  treatment  of  dislocations,  with  the  mode  of  ap- 
plying them. 

In  the  fifth  part  are  detailed  at  length  the  methods  of  per- 
forming such  operations  as  seem  strictly  to  be  included  in  the 
term  "  Minor  Surgery ;"  these  are  the  operations  for  bleed- 
ing, general  and  local ;  the  modes  of  effecting  counter-irrita- 
tion;—  the  methods  of  arresting  haemorrhage;  the  closure 
of  wounds ;  the  introduction  of  the  catheter,  and  the  adminis- 
tration of  injections.  A  few  remarks  on  the  mode  of  relieving 
pain  during  operations,  and  a  short  appendix  of  useful  for- 
mulae, close  the  volume. 

PHILADELPHIA,  May,  1848. 


TABLE  OF  CONTENTS. 


PREFACES PAGE  yii 

PART  I. 
CHAPTER  I. 

ON   THE   INSTRUMENTS    USED   IN   DRESSING 25 

CHAPTER  II. 

ON    SURGICAL   DRESSINGS. 

Lint—  Charpie  —  Cotton  —  Tow  —  The  Compress  —  Retractors— The 
Malta  Cross — Sponge-Tent — Setons — Adhesive  Plasters — Collodion 
— Soap  Plaster  —  Mercurial  Plaster  —  The  Poultice  —  The  Water 
Dressing  —  Spongio-Piline  —  Lotions — Cerates  —  Ointments — Lini- 
ments— The  Sponge 29 

CHAPTER-III. 

GENERAL  RULES  FOR  DRESSING 49 

CHAPTER  TV. 

ON   THE   USE    OP   WATER 52 

SECTION  I. 

IRRIGATION 52 

SECTION  II. 

THE   DOUCHE 54 

SECTION  III. 

BATHING. — WATER  AND  VAPOUR  BATHS 57 

(xi) 


CONTENTS. 
SECTION  IV. 

ON    FUMIGATIONS 61 

SECTION  V. 

ON    DISINFECTING  AGENTS 62 


PART  II. 

OH  BANDAGES   AND   THEIE  APPLICATION 65 

CHAPTER  I. 
SECTION  I. 

THE   ROLLER,   OR   SIMPLE    BANDAGE. 

Composition  and  preparation  of  the  Roller — Different  modes  of  appli- 
cation— Circular — Spiral  and  reversed  turns — Crossed — Spica  and 
recurrent  bandages — Uniting — Dividing — Compressing — Expelling 
— Retaining  and  Knotted  bandages 66 

SECTION  II. 

COMPOUND  BANDAGES. 

The  T  bandage — The  Invaginated — The  Split,  or  Tailed— The  Laced 
— The  Sheath — And  the  Suspensory  band  ages 72 

SECTION  III. 
M.  MAYOR'S  SYSTEM  OF  BANDAGES.. 76 

CHAPTER  II. 

REGIONAL   BANDAGING. 

SECTION    I. 
BANDAGES    FOR   THE    HEAD   AND   NECK. 

The  Recurrent — The  T — The  Four-tailed — The  Six-tailed  bandages 
— The  Fronto- occipital  Triangle— The  Knotted — The  Four-tailed 
bandage  of  the  Chin— The  T-bandage  of  the  Ear— The  double  T- 
bandage  of  the  Nose — The  sheath  of  the  Nose — Bandages  for  the 
Eyes— The  Invaginated  bandage  of  the  Lip — The  Sheath  of  Pibrac 
for  the  Tongue— The  Mask  for  the  Face — The  Cervical  Cravat — 
The  flexor  bandage  of  the  Neck— Jorg's  flexor  of  the  Neck 77 


CONTENTS.  XU1 

SECTION  II. 

BANDAGES    FOR   THE   TRUNK. 

The  Dorse-thoracic  Triangle — Circular  bandage — The  bandage  of  Vel- 
peau — The  figure-8  bandage  of  the  shoulders — The  Suspensory  of 
the  breast — The  triangular  cap  for  the  breast — The  Compressor  of 
the  breast— The  Straight-jacket — The  Body-bandage — The  -triangu- 
lar coverings  for  the  Sacrum  and  Pubis — The  triangular  bandage 
for  the  Groin — The  Cruro-inguinal  triangle  —  The  Spicas  of  the 
Groin — The  Cruro-inguinal  cravat — The  double  T-bandage  for  the 
Pelvis — Suspensories  of  the  Scrotum — Bandage  for  the  Penis 88 

SECTION   III. 

BANDAGES    FOR   THE   UPPER   EXTREMITIES. 

The  Axillo-clavicular  cravats — The  figure-8  bandage  for  the  shoulder 
and  axilla  —  Sling  for  the  fore-arm  —  Triangular  bandages  for  the 
Wrist  and  hand  —  The  Spiral  for  the  arm  —  The  Spica  for  the  arm 
and  shoulder — The  Spica  for  the  thumb — The  Gauntlet — The  Demi- 
gauntlet — The  crafat  bandage  for  the  hand — The  perforated  ban- 
dage for  the  hand 99 

SECTION  IV. 

BANDAGES  FOR  THE  LOWER  EXTREMITY. 

The  Cruro-iliac  triangle — The  bandage  of  Scultetus — The  eighteen- 
tailed  bandage — The  invaginated  bandages — The  figure-8  bandage 
for  the  knee — Weiss'  elastic  knee-cap — Common  elastic  cap  for  the 
knee — Spiral  bandages  for  the  lower  extremity — Baynton's  bandage 
—The  laced  stocking— The  Gaiter 104 


PART   III. 

BANDAGES  AND  APPARATUS  EMPLOYED  IN  THE  TREATMENT  OF  FRACTURES. 

CHAPTER  I. 

GENERAL   CONSIDERATIONS. 

Mode  of  reparation  of  fracture — Indications  of  treatment — "  The  Im- 
movable Apparatus"  of  Larrey,  Seutin,  Velpeau,  Laugier,  and 
Dieffenbach — The  "  Hyponarthecia"  of  Sauter  and  Mayor — Vehicle 
for  transporting  injured  persons — Mode  of  exposing  the  seat  of  in- 
jury— Fracture-beds — Clinical  frame — The  apparatus  of  Jenks,  for 
raising  the  patient  from  the  bed 108 

2 


*1V  CONTENTS. 

CHAPTER   II. 

BANDAGES  AND  DRESSINGS  FOR  FRACTURES  OF  THE  BONES  OF  THE  HEAD 
AND  TRUNK. 

SECTION  I 

FOR  FRACTURES  OF  THE  BONES  OF  THE  SKULL  AND  FACE. 

Of  the  bones  of  the  Cranium— Of  the  Face — The  four-tailed  bandage 
of  the  chin,  for  fractures  of  the  lower  jaw — Gibson's  and  Barton's 
bandages  for  the  same 121 

SECTION  II. 

BANDAGES    FOR   FRACTURES    OF   THE    BONES    OF   THE   TRUNK. 

For  fractures  of  the  Vertebrae  —  Of  the  Ribs  and  Sternum  —  Treat- 
ment by  compresses  and  a  roller — By  lath  or  pasteboard  splints — 
Fractures  of  the  Sternum — Fractures  of  the  bones  of  the  Pelvis — 
Treatment  of  compound  fractures '. 124 

CHAPTER  III. 

APPARATUS  AND  DRESSINGS  FOR  FRACTURES  OF  THE  BONES  OF  THE  SHOULDER. 

SECTION    I. 
FOR   FRACTURES    OF   THE   CLAVICLE. 

Older  methods  of  treatment — Fox's  apparatus — Bandage  of  Mr.  Lons- 

dale— Of  Brown — New  plan  recommended  by  M.  Guillou 128 

SECTION   II. 

FOR  FRACTURES    OF   THE    SCAPULA. 

Fractures  of  the  body  and  inferior  angle  —  Of  the  coracoid  process 
— Bandage  of  M.  Velpeau  —  Of  the  acromion  process  and  neck- 
Mr.  Lonsdale's  mode  of  treatment — Other  apparatus— Compound 
fractures 133 

CHAPTER  IV. 
SECTION  I. 

FOR   FRACTURES   OF   THE   HUMERUS. 

Fracture  of  the  shaft  of  the  bone — Ordinary  mode  of  treatment  — 
Mr.  Lonsdale's  splint  —  Fractures  of  the  upper  extremity  of  the 


CONTENTS.  XV 

bone  —  At  the  surgical  and  anatomical  neck  —  Fracture  at  the 
condyloid  extremity — Sir  A.  Cooper's  method  of  treatment  —  Mr. 
Mayo's  splint  for  compound  fractures  of  this  portion  of  the  bone — 
Treatment  of  compound  fractures  of  the  humerus  generally 138 

SECTION   II. 

FOR  FEACTUEES  OF  THE  BONES  OF  THK  FORE-ARM. 

Fractures  of  both  bones — Ordinary  method  of  treatment — Mr.  Lons- 
dale's  plan  —  The  "  Ante-brachial  Hyponarthecia"  of  Mayor — 
Fractures  of  the  radius— Of  the  head  of  the  bone — Of  the  shaft — 
Of  the  lower  portion  of  the  bone  —  Dupuytren's  splint — Oblique 
fracture  of  the  lower  end  of  the  radius  —  Modes  of  treatment  — 
Fractures  of  the  ulna— Of  the  coronoid  process — Of  the  olecranon 
process — Sir  A.  Cooper's  plan  of  treatment — Other  methods — Com- 
pound fractures — Partial  fractures 148 

SECTION  III. 

FOR  FRACTURES  OF  THE  BONES  OF  THE  WRIST  AND  HAND. 

Fracture  of  the  carpal  bones — Of  the  metacarpal  bones — Of  the  pha- 
langes— Compound  fractures 159 

CHAPTER  V. 

APPARATUS  AND  DRESSINGS  FOR  FRACTURES  OF  THE  BONES  OF  THE  LOWER 

EXTREMITY. 

SECTION    I. 
FOR  FRACTURES    OF   THE   OS    FEMORIS. 

Treatment  in  the  flexed  and  straight  positions  —  Treatment  of  frac- 
tures of  the  shaft  of  the  bone  —  By  the  method  of  Pott  —  Of  Sir 
Charles  Bell  —  Apparatus  used  at  the  Middlesex  Hospital  —  Plan 
of  Mr.  Amesbury — Splint  of  Dr.  N.  R.  Smith — Hyponarthecia  for 
fractures  of  the  thigh  —  Treatment  by  the  straight  splints  of 
Desault  —  Dr.  Physick's  modification  —  Splints  of  Boyer,  Listen, 
Hagedorn,  (as  modified  by  Dr.  Gibson),  and  others — Treatment  of 
fractures  of  the  upper  part  of  the  femur — Within  the  capsular  liga- 
ment—  Exterior  to  this  —  Fractures  of  the  lower  extremity  of  the 
bone — Above  the  condyles — Through  these  processes — Compound 
fractures  of  the  thigh 163 


. 

Xvi  CONTENTS. 

SECTION  II. 

FOR  FRACTURES  OF  THE  PATELLA. 

Longitudinal  and  transverse  fractures  —  Plans  of  treatment  pursued 
by  Sir  A.  Cooper,  by  Desault,  Gerdy,  Amesbury,  Lonsdale,  and 
others — Rupture  of  the  tendon,  and  ligament  of  the  patella — Com- 
pound fractures  of  the  patella 190 

SECTION  III. 

FOR  FRACTURES  OF  THE  BONES  OF  THE  LEG. 

Of  both  bones,  treatment  by  "the  Junks" — By  the  splint  of  Mr. 
Neville — By  the  fracture-box — By  the  splints  of  Hutchinson — By 
the  double  inclined  plane  of  Mr.  Listen — Other  methods — Fracture 
of  tibia  only  —  Of  the  fibula  only —  "Pott's  fracture" — Its  treat- 
ment according  to  Dupuytren  —  By  the  fracture-box  —  Suspension 
method  of  Sauter  and  Mayor  —  Compound  fractures  —  The  bran- 
dressing 197 

SECTION   IV. 

FOR  FRACTURES  OF  THE  BONES  OF  THE  FOOT. 

Of  the  os  calcis — Method  of  Mr.  Lonsdale — Of  Druitt — Simple  frac- 
tures of  the  bones  of  the  foot  generally — Compound  fractures 208 


PART    IV. 

ON  THE  MECHANICAL  MEANS    EMPLOYED   IN    THE  TREATMENT  OF  DISLOCATIONS. 

General  observations 208 

CHAPTER  I. 

DISLOCATIONS    OF   THE    BONES    OF   THE    HEAD   AND    TRUNK. 

SECTION  I. 

OF    THE    LOWER    JAW. 

Reduction  —  Retention  by  the  bandages  of  Barton  or  Gibson 212 

SECTION  II. 

OF  THE  BONES  OF  THE  TRUNK 213 


CONTENTS.  XV11 

SECTION   III. 

OF   THE    CLAVICLE. 

Reduction  —  Treatment  by  the  crucial  bandage 213 

CHAPTER  II. 

DISLOCATIONS    OF   THE    BONES   OF   THE    UPPER   EXTREMITY. 

SECTION  I. 

OF     THE     HUMERUS. 

Different  positions  assumed  —  Reduction  by  the  heel  in  the  axilla, 
with  the  double  roller  towel  —  By  relaxing  the  supra-spinatus  and 
deltoid  muscles  —  By  the  use  of  the  pulleys,  with  the  knee  in  the 
axilla — After  treatment 215 

SECTION  II. 

OF  THE  BONES  OF  THE  ELBOW. 

Varieties  of  the  accident — Restoration — Subsequent  treatment 220 

SECTION  III. 

OF  THE  LOWER  EXTREMITY  OF  THE  FORE-ARM. 

Varieties  —  Reduction  —  Subsequent  treatment 221 

SECTION  IV. 

OF  THE  BONES  OF  THE  HAND. 

Of  the  carpal  and  metacarpal  bones  — Reduction  of  the  phalanges  — 
Reduction  by  various  methods 221 

CHAPTER  III. 

DISLOCATIONS   OF   THE   BONES   OF   THE   LOWER   EXTREMITY. 

SECTION    I. 

OF   THE    HIP   JOINT. 

Varieties  — General  plan  of  reduction  —  Restoration  of  each  variety, 
with  subsequent  treatment  —  Restoration  by  means  of  the  twisted 
rope.... 224 

SECTION  II. 

OF   THE    PATELLA. 

Varieties  of  the  accident — Restoration  and  after-treatment 229 


XV1U  CONTENTS. 

SECTION   III. 

OF   THE    TIBIA   AT    THE    KNEE. 

Varieties — Their  mode  of  treatment 230 

SECTION  IV. 

OP   THE    HEAD    OP   THE   FIBULA. 

Reduction  and  subsequent  treatment... 2,30 

SECTION  V. 

OF   THE    ANKLE. 

Varieties  and  treatment 231 

CHAPTER  IV. 

COMPOUND   DISLOCATIONS. 

Mode  of  treatment 232 

Apparatus  for  the  relief  of  partial  anchylosis 233 

PART  V. 
CHAPTER  I. 

ON    SOME    OF    THE    MINOR    SURGICAL    OPERATIONS. 

On  the  making  of  incisions 235 

CHAPTER  II. 

ON    BLOODLETTING 241 

SECTION   I. 

OPERATIONS  FOR  GENERAL  BLEEDING. 

Phlebotomy  at  the  bend  of  the  arm  —  Choice  of  the  vein  —  Prelimi- 
nary arrangements — Position  of  the  patient — Choice  of  the  arm — 
Of  the  lancet — Mode  of  operating  with  the  thumb-lancet  and  with 
the  spring-lancet — Difficulties  attending  the  operation,  and  modes 
of  obviating  them  —  Mode  of  dressing  the  wound  —  Bleeding  from 

the  hand — From  the  ankle  —  From  the  external  jugular  vein 241 

Accidents  attending  phlebotomy 253 

Thrombus — Its  causes — Treatment  and  mode  of  prevention 277 

"Wound  of  a  nerve 254 

Symptoms  of  the  accident — Treatment 254 

Wound  of  an  artery '. 255 

Mode  of  recognising  the  injury — Treatment  by  compression 255 

Wound  of  a  tendon — Treatment 256 

Arteriotomy 257 


CONTENTS.  XIX 

Opening  of  the  temporal  artery — Operation  of  Magistel — Incision  of 

one  of  the  branches,  as  advised  by  Velpeau 258 

SECT  ION  II. 

ON   TOPICAL    BLEEDING. 

On  Cupping  —  Dry-cupping  —  Modes  of  operating  —  Wet-cupping  — 
Apparatus  required  —  Mode  of  lessening  the  pain  attending  the 

application  of  cups 258 

On  the  application  of  leeches 261 

Modes  of  arresting  bleeding  from  leech-bites 263 

Mode  of  preserving  the  leech 264 

Scarification  as  a  means  of  local  depletion 265 

CHAPTER  III. 

ON  THE  MODES  OP  EFFECTING  COUNTER-IRRITATION 266 

SECTION  I. 

RUBEFACIENTS. 

Hot  water — Sand — The  oils,  &c. — Sinapisms — Mode  of  their  employ- 
ment— "The  spice  poultice" — Preparation..., 266 

SECTION  II. 

VESICANTS. 

Boiling  water — Hot  metal — Steam — Spanish  flies — Mode  of  employ- 
ing the  cerate — Application  of  the  vesicant — Treatment  of  the  blis- 
tered surface — Mode  of  relieving  strangury  —  Cases  to  which  this 
agent  is  applicable — Croton  oil  —  Its  mode  of  action  and  employ- 
ment— Croton  oil  plaster — The  strong  water  of  ammonia  —  Mode 
of  employment — Granville's  lotions  268 

SECTION   III. 

SUPPURATIVE    COUNTER-IRRITANTS. 

Mineral  acids — The  actual  cautery,  &c. — Tartar  emetic — Application 
of  the  ointment — Dressing  of  the  surface  —  Tartar  emetic  in  solu- 
tion and  in  plaster  —  Nitrate  of  silver  —  Application  and  uses  — 
Caustic  potassa — Mode  of  employment — Dressing  of  the  surface — • 
"  The  Vienna  paste"  —  M.  Canquoin's  chloride  of  zinc  paste  — 
White  oxide  of  arsenic  —  The  actual  cautery — The  moxa,  prepara- 
tion and  employment — Issues  —  Their  formation  —  Point  of  inser- 
tion— Setons — Composition  —  Mode  of  employment — Acupuncture 
— Operation  —  Electro-puncture  —  Uses — Vaccination — Collection 
and  preservation  of  the  vaccine  virus  —  Modes  of  inserting  the 
matter 273 


XX  CONTENTS. 

CHAPTER   IV. 

METHODS    OF   ARRESTING   HAEMORRHAGE. 

By  the  action  of  cold — Of  astringents  and  styptics — Matico — By  can- 
terization,  with  the  actual  or  potential  cautery — By  pressure  with 
the  hand,  or  tourniquet  —  By  plugging  the  wound,  or  divided  ves- 
sel —  By  torsion  —  By  the  application  of  the  ligature  —  Mode  of 
arresting  epistaxis,  and  haemorrhage  from  the  rectum 282 

CHAPTER  V. 

ON   THE    DRESSING   OP   WOUNDS. 

Cleansing  of  the  wound  —  Arrest  of  bleeding  —  Treatment  of  granu- 
lating wounds  —  Modes  of  securing  the  apposition  of  the  edges  of 
incised  wounds — By  adhesive  strips  of  lead-plaster,  isinglass-plas- 
ter, and  by  means  of  the  solution  of  gun-cotton  —  By  the  inter- 
rupted suture — By  the  continued  suture— By  the  quilled  suture — 
By  the  twisted  suture  —  By  the  dry  suture  —  By  invaginated  and 
other  bandages 302 

CHAPTER  VI. 

ON   THE   INTRODUCTION   OF    THE   CA.THETER. 

Catheterism  of  the  eustachian  tube — The  instrument  and  manner  of 
introducing  it — Catheterism  of  the  oesophagus — The  stomach- tube, 
and  mode  of  using  it — Catheterism  of  the  urethra — Construction  of 
the  catheter,  male  and  female,  and  the  various  plans  for  intro- 
ducing it  into  the  bladder — Mode  of  obviating  difficulties — Mode  of 
securing  the  catheter  in  the  bladder  —  Catheterism  of  the  large 
intestine— Catheterism  of  the  air-passages 312 

CHAPTER  VII. 

ON   THE   ADMINISTRATION   OP   INJECTIONS. 

Composition  of  and  apparatus  for  injections  —  Injections  by  the  rec- 
tum —  Syringes  and  mode  of  employment  —  Preparation  of  the 
enema — Suppositories  —  Injections  by  the  vagina  —  Injections  by 
the  urethra — Injections  by  the  lachrymal  duct 327 

CHAPTER  VIII. 

ON   THE   REMOVAL   OP   FOREIGN   BODIES    PROM   THE   NATURAL   CANALS   AND 

PASSAGES 333 

MEANS    OP   DIMINISHING   PAIN   DURING   OPERATIONS. 

Administration  of  opium  —  Of  the  vapours  of  vegetable  narcotics, 
and  nitrous  oxide  gas — Inhalation  of  sulphuric  ether  and  chloro- 
form vapours 346 

APPENDIX   OF   FORMULAE. 

Lotions — Cerates — Ointments — Liniments 350 


LIST    OF    ILLUSTRATIONS 


no.  PAQB 

1  Dressing  forceps 26 

2  Scalpel 26 

3  Double  Catheter 27 

4  Graduated  compress,  from  Cutler 33 

5  Pyramidal         "                  "           33 

6  Malta  cross,                        "           34 

7  Treatment  of  epididymitis  by  compression,  from  Velpeau 37 

8  Hays' bandage  for  retaining  dressings 41 

9  "            "       applied  to  the  leg 41 

10  Arch  of  hoop,  from  South , 50 

11  Apparatus  for  irrigation,  from  Velpeau 53 

12  Portable  shower-bath,  from  Thomson , 56 

13  "        bathing-apparatus,  from  Thomson 59 

14  Vessel  for  the  hip-bath,                 "                60 

15  Machine  for  rolling  bandages 66 

16  Different  applications  of  the  roller,  from  Cutler 68 

17  Mode  of  making  reversed  turns,  from  Velpeau 69 

18  Crossed  bandage  of  the  elbow,  from  Cutler 70 

19  Recurrent  bandage  of  the  head,  from  Velpeau 78 


20  Four-tailed 

21  Six-tailed 

22  Four-tailed 

23  Double  T 

24  Monocle 

25  Invaginated 


Cutler 79 

"  "     Velpeau 80 

of  the  chin,      "      Cutler 81 

of  the  nose,      "          "     82 

from  Culver 84 


of  the  lip,  from  Smith 84 

26  Purse  of  Pibrac  for  the  tongue,  from  Velpeau 85 

27  Flexor  bandage  of  the  neck,  from  Velpeau 86 

28  Jorg's  apparatus  for  wry-neck,  from  Cutler , ...  87 

29  Compressing  bandage  of  the  chest,  from  Velpeau 89 

30  Crossed                 "                       "             "               90 

31  Compressing        "        of  the  abdomen,    "               94 

32  Triangular           "        of  the  groin,          " 95 

33  Cruro-inguinal  triangle,  from  Cutler 95 

34-5  Suspensory  of  the  scrotum,  from  Cutler 97 

36  Suspensory  triangle,  from  Cutler 98 

37  Spica  bandage  of  the  shoulder,  from  Velpeau 101 

88  Gauntlet,  from  Velpeau 103 

(xxi) 


XX11  LIST. OF    ILLUSTRATIONS. 

n<1-  PACK 

39  Demi-gauntlet,  from  Velpeau : 103 

40  Spiral  bandage  of  the  leg 106 

41  Pasteboard  splint  for  the  chin,  from  Cutler 122 

42  Gibson's  bandage  for  fracture  of  the  lower  jaw,  from  Gibson 123 

43  Barton's         "  "  "         123 

44  Fox's  apparatus  for  fracture  of  the  clavicle 1 131 

45  Lonsdale's  apparatus  for  fracture  of  the  clavicle,  from  Lonsdale 131 

46  Velpeau's  bandage  for  fracture  of  the  shoulder,  from  Velpeau ,.  135 

47  Lonsdale's       "  "  acromion,  from  Lonsdale 136 

48  Splint  for  fractures  of  the  humerus,  from  Lonsdale 140 

49  Fracture  of  humerus,  above  the  condyles,  from  Cooper 142 

50  "  "         through  the  condyles,  from  Lonsdale 143 

51  Splints  for  the  treatment  of  this  accident,  from  Cooper 144 

52  Mayo's  splint  for  compound  fractures,  from  Lonsdale 146 

53  Ante-brachial  hyponarthecia,  from  Cutler 150 

54  Dupuytren's  splint  for  fracture  of  the  radius,  from  Lonsdale 151 

55  Oblique  fracture  of  the  lower  end  of  the  radius,  from  Fergusson....  152 

56  Ne"laton's  splint  for  radius,  from  Erichsen 153 

67-8  Bond's      "  "         "      American  MedicalJournal 154 

59  Hay's  "  "         "  «  «  155 

60  Treatment  of  fracture  of  the  olecranon  process  of  the  ulna,  from 

Cooper 157 

61  Olecrano-metacarpal  cravat,  from  Cutler 158 

62  Splint  for  fractures  of  the  bones  of  the  hand,  from  Lonsdale 161 

63  Double  inclined  plane,  from  Lonsdale 167 

64  The  same  applied 168 

65  Mr.  Amesbury's  double  inclined  plane,  from  Amesbury 169 

66  The  same  applied,  from  Amesbury 170 

67  Dr.  N.  R.  Smith's  splint,  from  H.  H.  Smith , 172 

68  M'Intyre  and  Liston's  splint,  from  Fergusson 172 

69  The  long  splint  of  Desault..., 174 

70  Gaiter  for  extension 175 

71  Cravat  band  for  extension 177 

72  Boyer's  apparatus  for  fracture  of  the  thigh,  from  Cutler 181 

73  Liston's  splint  "  "         "      Fergusson 181 

74  Kimball  and  Sanborn's  splint,  from  Miller 182 

75  Gibson's  Hagedorn's  apparatus,  from  Gibson 183 

76  Treatment  of  fracture  of  the  great  trochanter,  from  Cooper 187 

77  Straight  splint  for  compressed  feet,  from  Erichsen 189 

78  Treatment  of  fracture  of  the  patella,  from  Cooper 191 

79  "  «  "  «  192 

80  Lonsdale's  apparatus  for  the  same,  from  Lonsdale 193 

81  Wood  splint,  for  fracture  of  the  patella,  from  Fergusson 195 

82  Fracture-box 199 

83  A  fractured  leg,  from  Fergusson 199 

84  Fergusson's  splint  for  fractured  leg 202 

85  Suspension  apparatus,  from  Fergusson 203 

86  Mr.  Liston's  splint,  double  plane,  from  Fergusson.i 204" 

87  "Pott's  fracture"  of  the  fibula,  from  Lonsdale 205 

88  Dupuytren's  treatment  of  the  same,  from  Lonsdale 206 

89  Mode  of  treatment  of  fracture  of  the  os  calcis,  from  Lonsdale 209 

90  "  "  "  "  "     Druitt 209 

91  Dislocation  of  the  lower  jaw,  from  Druitt. 212 


LIST     OF     ILLUSTRATIONS.  XXlll 

FIO.  PAGE 

92  Bandage  for  treatment  of  dislocation  of  clavicle,  from  Druitt 214 

93  Reduction  of  dislocation  of  the  humerus,  from  Cooper 216 

94  "  "  «<  "  216 

95  Pulleys  and  staple,  from  Fergusson 217 

96  Reduction  of  dislocation  of  the  humerus,  from  Cooper 218 


97 
98 
99  "  The  clove-hitch, 


phalanx,  from  Fergusson 222 

222 
'  from  Fergusson 223 


100  Reduction  of  dislocation  of  the  thumb,  from  Cooper 223 

femur,  «  225 


226 

«  227 

"  228 


101 

102  « 

103  " 

104  " 

105  "  "  "        from  Fergusson 228 

106  Apparatus  for  the  relief  of  partial  anchylosis,  from  Mutter 233 

107  Manner  of  holding  the  knife,  from  Fergusson 236 

108  "  "  "  "  236 

109  "  "  "  "  236 

110  "  opening  an  abscess        "  237 

111  "  "  "  " 237 

112  Plan  of  crucial  incision,  from  Fergusson 238 

113 

114  « 

115  <  « 
116 

117 


elliptical  incisions,  from  Fergusson 238 

variously  shaped  incisions,  from  Fergusson 238 


238 
238 
238 

118  Incision  guided  by  the  finger,  from  Fergusson 239 

119  Tenotomy-knife,  from  Miller 239 

120  Another  pattern,  from  Erichsen 240 

121  Disposition  of  the  veins,  &c.,  at  the  bend  of  the  arm,  from  Wilson.  242 

122  "  "  "  "  Druitt..  242 

123  Position  of  the  lancet  in  bleeding,  from  Fergusson 248 

124  Bleeding  from  the  jugular  vein  and  temporal  artery,  from  Velpeau.  252 

125  Plan  of  compressing  an  artery,  from  Miller 256 

126  Seton  needle,  armed,  from  Fergusson 277 

127  Eyed  probe,  as  a  substitute  for  the  above,  from  Erichsen 277 

128  Forms  of  the  actual  cautery  irons,  from  Liston  and  Mutter 285 

129  Compression  of  the  brachial  artery,  from  Fergusson , 287 

130  "  femoral  "  287 

131  The  tourniquet,  from  Fergusson , 288 

132  "         applied  to  the  arm,  from  Fergusson 289 

133  "  «          "       thigh,       "  289 

134  "  "          "       popliteal  region,  from  Fergusson...  289 

135  Field          "  "          "       arm,  from  Liston  and  Mutter 290 

136  The  compressor  of  Dupuytren  applied  to  the  thigh,  from  Liston  and 

Mutter 290 

137  Compressor  for  middle  of  thigh,  from  Erichsen 292 

138  "  groin,  "  292 

139  Carte's  improved  circular  compressor,  from  Fergusson 293 

140  Serrated  forceps,  from  Fergusson 294 

141  Plan  of  making  torsion,  from  Fergusson 294 

142  The  toothed  forceps,  from  Fergusson 295 

143  The  tenaculum,  from  Fergusson 296 


XXIV  LIST    OF    ILLUSTRATIONS. 


144  The  sailor's  knot,  from  Fergusson  ...........................................  296 

145  The  common  aneurism-needle,  from  Fergusson  ...........................  298 

146  Physick's  forceps,  from  Liston  and  Mutter  ...........  ,  .....................  299 

147  Mode  of  plugging  the  nostrils,  from  Liston  and  Mutter  ................  300 

148  Belloc's  instrument  for  the  same,  from  Liston  and  Mutter  ............   300 

149  The  interrupted  suture,  from  Fergusson  ....................  «  ..............  306 

150  The  quilled  suture,  from  Druitt.  .  ..............................  .  .............  307 

151  Surgeons'  needles,  from  Fergusson  ..........................................   307 

152  The  hare-lip  suture,       "  .........................................  308 

153  Apparatus  to  aid  the  hair-lip  suture,  from  Fergusson  ..................   308 

154  The  invaginated  bandage  for  longitudinal  -wounds,  from  Cutler  .....  310 

155  Same  applied,  from  Cutler  ......................  .  ..............................  310 

156  Invaginated  bandage  for  transverse  wounds,  from  Cutler  .............  311 

157  View  of  the  course  of  the  lachrymal  passages,  from  Lawrence  ......  312 

158  Anel's  probe  for  dilating  the  lachrymal  puncta  and  canals  ............  313 

159  Probe  for  dilating  the  nasal  duct,  from  Lawrence  ........................  313 

160  Morgan's  probe  for  the  same,  from  Lawrence  ............................  314 

161  Eustachian  tube  catheter,  from  Wilde  ......................................  315 

162  Catheters  for  the  male  urethra,  from  Fergusson  ..............  ..  ..........  319 

163  Introduction  of  the  male  catheter  ............................................  320 

164  Obstruction  to  catheterism  from  enlarged  prostate,  from  Druitt....  822 

165  Velpeau's  mode  of  securing  the  catheter  in  the  bladder,  from  Vel- 

peau  ..............................................................................   324 

166  Double  catheter  and  Read's  syringe  for  injecting  the  bladder,  from 

Fergusson  ........................................................................  331 

167  Mr.  Wilde's  ear  speculum  ......................................................  335 

168  Wilde's  gorget-like  speculum  auris  ..................  ,  .......................  335 

169  Forceps  and  curette,  from  Wilde's  Aural  Surgery  .......................   336 

170  Curved  forceps  for  the  external  ear,  from  Wilde's  Aural  Surgery...  336 

171  Probang,  from  Fergusson  .............................  .  .......  .................  337 

172  Removal  of  foreign  body  by  the  gullet  forceps,  from  Fergusson  .....  337 

173  Hook  for  removing  foreign  bodies  from  gullet,  from  Fergusson  .....   338 

174  Bond's  hook  for  removal  of  bodies  from  gullet  ...........................  338 

175  Gullet  forceps,  from  Miller  ....................................................  339 

176  Bond's  gullet  forceps  .............................  .  ..............................  339 

177  Civiale's  urethra  forceps,  from  Fergusson  .................................  343 

178  Weiss'  metallic  urethra  dilator,  from  Fergusson  .........................  344 

179  Scoop  for  removing  foreign  substances  from  the  rectum,  from  Fer- 

gusson ...........................................................................  345 

180-181  Inhalers,  from  Pereira  ....................................................  348 


MINOR    SURGERY. 


PART    I. 

THE  means  employed  by  the  surgeon  in  the  treatment  of 
the  diseases  to  which  he  is  ordinarily  called,  should  first 
engage  our  attention :  they  are,  in  a  measure,  of  a  mechanical 
and  chemical  kind.  This  part  of  the  volume  will  therefore  be 
devoted  to  the  consideration : 

First.  Of  the  instruments  which  it  is  most  necessary  to 
provide  for  daily  use. 

Second.  Of  the  materials  employed  for  surgical  dressings, 
and  the  mode  of  applying  them, —  including  the  use  of  water 
as  a  local  application,  and  for  bathing. 

Third.  Of  the  means  of  purifying  the  atmosphere  of  the 
patient's  apartment. 


CHAPTER   I. 

ON   THE   INSTRUMENTS   USED   IN   DRESSING. 

THE  instruments  which  the  daily  avocations  of  the  surgeon 
call  for  are  of  various  kinds.  For  convenience-sake  they  are 
arranged  in  a  "  pocket-case."  They  may  be  multiplied 
according  to  the  fancy  of  the  surgeon ;  but  those  which  will 
be  found  most  useful  are,  the  dressing  and  dissecting  forceps, 
a  pair  of  scissors,  bistouries,  scalpels,  a  thumb-lancet,  an 
abscess  lancet,  a  director,  probes,  a  tenaculum,  curved  needles, 
a  porte-caustic,  a  double  catheter,  and  ligatures. 

3  (25) 


26  INSTRUMENTS    USED    IN    DRESSING. 

The  uses  of  the  dressing  forceps  are  manifest,  in  the  re- 
moval of  soiled  dressings,  covered,  as  they  very  often  are, 
with  acrid  and  irritating  secretions;  in  the  loosening  and 
withdrawal  of  decayed  bone,  and  other  foreign  matters,  from 
sinuses,  deep  wounds,  and  such  points  as  are  of  difficult  access 
to  the  fingers  alone.  .For  such  purposes  the  common  dissect- 
ing-forceps  will  frequently  answer.  But  the  proper  Dressing- 
forceps  is  of  a  more  suitable  shape,  as  illustrated  by  the  ac- 
companying drawing  (fig.  1).  A  still  better  form  is  that  of 

FIG.  1. 


the  French  Polypus-forceps,  the  blades  being  bent  in  front 
of  the  pivot,  so  that  the  instrument  occupies  less  space  in  the 
wound  or  sinus,  when  opened  than  when  closed. 

The  scissors  used  by  the  surgeon  may  be  straight  or 
curved. 

There  should  be  two  bistouries  in  the  pocket-case :  a 
sharp-pointed  and  a  probe-pointed.  The  circumstances  in 
which  each  will  be  most  advantageously  employed,  will  rea- 
dily suggest  themselves  to  the  operator. 

There  is  great  variety  of  opinion  as  to  the  best  form  and 

FIG.  2. 


size  for  the  Scalpel.  Mr.  Fergusson  prefers  one  of  the  shape 
and  dimensions  indicated  in  the  annexed  drawing  (fig.  2),  the 
blade  and  handle  together  being  about  six  inches  long.  With 
such  a  scalpel  in  his  pocket-case,  one  may  perform  almost  any 


INSTRUMENTS    USED    IN    DRESSING. 


27 


FIG.  3. 


of  the  capital  operations  of  surgery,  so  far  as  mere  cutting  is 
concerned. 

The  director  and  the  probes  should  be  of  silver,  as  being 
flexible,  and  less  liable  to  be  injured  by  contact  with  the 
various  fluids  with  which  they  will  meet,  than  if  made  of  steel. 
The  probes  should  be  of  various  sizes,  and  one  should  be  made 
with  an  eye  in  its  flattened  extremity,  for  the  purpose  of  being 
armed,  if  occasion  require,  with  a  ligature,  a  skein  of  silk,  or 
a  piece  of  tape. 

The  porte-caustic  should  be 
of  platinum,  as  this  metal  best 
resists  the  action  of  nitrate  of 
silver,  which  is  the  caustic  ge- 
nerally carried  in  the  pocket- 
case.  The  platinum  cup  may 
be  fitted  to  a  stem  of  wood,  or 
it  may  be  so  made  as  to  be  re- 
ceived into  a  silver  case ;  the 
latter  is  the  best  arrangement. 
In  addition  to  the  lunar  caustic, 
the  surgeon  will  find  it  conve- 
nient, oftentimes,  to  have  a 
crystal  of  the  sulphate  of  copper 
in  his  case.* 

The  double  catheter  is  made 
of  silver,  as  is  the  common  male, 
or  female,  catheter.  It  con- 
sists of  three  pieces,  as  repre- 
sented in  the  annexed  drawing, 
(see  fig.  3.)  A,  a  straight  tube, 
about  five  inches  long,  having 
at  its  upper  extremity  two  rings 
firmly  soldered  to  the  tube  at 
points  opposite  to  each  other ; 
while  the  lower  extremity  has  a 
female  screw-thread  cut  upon  it, 
of  half  an  inch  in  length  :  B, 
a  beak,  an  inch  and  a  half  or 
two  inches  long,  slightly  curved, 
its  lower  extremity  closed  and 
rounded,  while  the  upper  end  is  provided  with  a  male  screw, 


28  INSTRUMENTS    USED    IN    DRESSING. 

corresponding  with  the  female  screw  of  the  staff  which  is  in- 
tended to  receive  it.  Just  above  the  lower  extremity  of  this 
beak,  two  oval  or  rounded  fenestrae  are  cut,  one  on  each 
side,  thus  throwing  open  the  cavity :  C,  another  beak,  about 
seven  inches  long,  having  a  curve  similar  to  that  of  the  or- 
dinary male  catheter,  and  its  upper  and  lower  extremities 
adjusted  as  are  those  of  the  shorter  beak.  By  simply 
screwing  the  short  curved  piece  to  the  staff,  we  have  an  ele- 
gant female  catheter ;  by  similarly  attaching  the  long  curve, 
a  male  catheter.  When  in  the  pocket-case,  the  short  beak 
should  be  kept  screwed  to  the  staff. 

This  instrument  is  very  well  made  by  Mr.  Warner  of  this 
city,  Commerce  Street.  The  tube  should  be  thicker  and 
stronger  than  that  of  the  ordinary  catheter,  and  care  should 
be  used  that  the  joints  be  accurately  fitted. 

The  advantages  of  having  so  important  an  instrument  as 
this  reduced  to  a  form  so  portable,  need  not  be  insisted  upon. 

In  addition  to  the  instruments  above  enumerated,  the 
pocket-case  may  be  made  to  include  a  spatula,  a  double  canula 
with  its  wire,  a  seton-needle,  and  a  razor.  These,  however, 
are  not  so  essential  elements  of  the  case,  as  those  before 
mentioned ;  generally  they  can  be  dispensed  with,  or  other 
instruments  may  well  be  used  in  their  stead ;  and  their  pre- 
sence will  render  the  pocket-case  much  more  *bulky  and 
cumbersome. 

The  blades  of  the  bistouries  and  scalpels  may  be  so  made 
as,  when  not  in  use,  to  be  concealed  within  the  handle,  as  the 
blades  of  the  ordinary  pocket-knife;  by  this  arrangement, 
the  edge  of  the  instrument  will  be  protected  from  injury. 


CHAPTER   II. 

ON    SURGICAL    DRESSINGS. 

THE  various  appliances  used  in  surgical  dressings  may  be 
thus  enumerated:  lint,  cotton,  tow,  compresses  of  various 
kinds  and  forms,  sponge-tent,  setons,  adhesive  and  other  plas- 
ters, poultices,  lotions,  cerates,  ointments,  liniments,  bandages, 
sponge,  and  apparatus  of  various  kinds,  more  or  less  complex, 
for  special  purposes.  Some  description  of  each  of  these  -will 
be  necessary. 

1.  LINT  is  the  soft  fleecy  substance  obtained  by  unravelling 
old  linen.  It  may  be  procured  in  the  shops  in  the  form  of 
what  is  called  "  patent  lint,"  or  it  may  be  prepared  as  required 
for  use,  by  scraping,  with  a  sharp  knife,  the  surface  of  old 
linen,  previously  put  upon  the  stretch.  The  linen  selected  for 
its  preparation  should  be  soft,  from  use  and  washing.  As 
thus  obtained,  the  lint  is  very  light  and  delicate,  and  admi- 
rably adapted  to  absorb  the  secretions  of  parts  to  which  it 
may  be  applied.  The  "  patent  lint"  is  sold  in  sheets  or  rolls, 
one  of  its  surfaces  is  fleecy,  the  other  is  smooth :  its  texture 
is  compact,  certainly  not  nearly  so  porous  as  the  loose  lint ; 
hence  it  absorbs  much  less  readily  and  freely  than  the  latter. 
Both  varieties  of  lint  are  applied  dry,  or  covered  with  cerates, 
or  saturated  with  some  kind  of  lotion. 

The  French  surgeons  employ  an  admirable  sort  of  lint, 
which  they  term  "  char  pie."  It  is  now  very  generally  used 
in  this  city,  and,  indeed,  throughout  the  country,  when  it  can 
be  procured.  It  is  thus  made  : — linen,  of  a  coarse  or  fine  tex- 
ture, according  to  circumstances,  is  cut  into  small  pieces,  a  few 
inches  square,  and  its  tissue  completely  unravelled,  thread  by 
thread.  The  coarser  kind  of  charpie  may  be  made  of  old 
table-cloths ;  the  finer  sort  of  a  lighter  material.  Velpeau 
gives  a  decided  preference  to  charpie  made  of  old  linen,  as 
being  much  more  absorbent,  and  much  less  irritating,  than 
that  made  of  the  new  fabric. 

(Charpie  of  an  excellent  quality  is  made  in  this  city  by  Mrs. 
3*  (29) 


30  SURGICAL    DRESSINGS. 

Jones,  southwest  corner  of  Walnut  and  Juniper  streets,  and  is 
kept  for  sale  in  many  of  the  apothecary  shops.) 

Lint,  in  its  various  forms,  is  used  as  a  simple  application  to 
ulcerated  or  excoriated  surfaces;  to  favour  an  equable  and 
even  pressure  upon  any  part ;  to  prevent  adhesion  between  the 
walls  of  cavities,  natural  or  accidental ;  to  absorb  various  se- 
cretions, and  as  a  vehicle  by  which  medicinal  applications  may 
be  made,  when  and  wherever  required. 

Various  arbitrary  terms  have  been  applied  to  no  less  arbi- 
trary forms,  which  lint,  and  especially  charpie,  may  be  made 
to  assume,  as  an  element  of  surgical  dressings.  Thus,  there 
is  the  plumasseau  or  pledget,  the  roll,  the  bullet,  the  mesh, 
the  tent,  the  tampon,  the  pellet,  &c. 

The  PLUMASSEAU  is  prepared  by  simply  folding,  at  the  mid- 
dle, a  sufficient  number  of  the  filaments  of  charpie,  previously 
laid  parallel  to  each  other.  For  the  sake  of  neatness,  the 
ends  of  the  threads  may  be  cut  off  evenly,  or  inverted,  and 
the  mass  thus  formed  moulded  by  the  hands  to  any  shape,  flat, 
round,  circular,  square,  or  oblong,  to  adapt  it  to  particular 
parts. 

The  ROLL  is  a  mass  of  charpie,  rendered  cylindrical  by  the 
hands,  and  firmly  tied  at  the  middle.  It  is  chiefly  used  to  ar- 
rest hemorrhage,  by  pressure,  from  a  deep-seated  vessel,  or  to 
absorb  the  secretions  from  wounds  or  cavities.  For  conveni- 
ence in  withdrawing  the  mass,  the  string,  tied  about  the  mid- 
dle, may  be  left  attached  at  this  point,  and  projecting  from 
the  orifice. 

The  term  BULLET  is  applied  to  a  small  mass  of  charpie  or 
common  lint,  rolled  into  the  form  of  a  small  ball.  A  number 
of  these  may  be  advantageously  used  for  the  same  purposes 
as  the  roll  just  described. 

The  MESH  resembles  the  roll  very  much  in  its  uses  ;  its 
fibres  are  left  loosely  floating,  instead  of  being  rolled  together. 
It  is  sometimes  employed  in  the  treatment  of  sinuses  and 
fistulous  canals,  by  being  thrust  to  the  bottom  of  such  cavi- 
ties, on  the  end  of  a  probe,  with  the  view  of  preventing  their 
healing  at  the  orifice.  It  may  be  introduced  dry,  or  covered 
with  some  lotion  or  cerate,  more  or  less  stimulating. 

The  TENT  of  charpie  is  made  by  twisting  a  certain  amount 
of  this  substance  into  the  form  of  a  cone.  For  the  purposes 


SURGICAL    DRESSINGS.  31 

for  which  a  tent  is  generally  required,  it  is  very  much  inferior 
to  the  sponge-tent. 

The  TAMPON  is  merely  a  large  ball  of  charpie,  or  it  may 
be  a  number  of  bullets.  It  is  used  in  the  plugging  of  bleed- 
ing wounds,  &c. 

The  PELLET  consists  of  a  ball  of  charpie  or  common  lint, 
enclosed  in  a  piece  of  soft  linen,  firmly  tied.  It  may  be  used 
as  a  tampon. 

The  good  sense  of  the  surgeon  or  dresser  will  enable  him 
to  employ  these  different  forms  of  lint  seasonably,  or  to 
invent  others  still  better. 

2.  COTTON  may  be  used  with  advantage  in  many  cases. 
•  Its  cheapness — and  the  almost  universality  of  its  diffusion — 

are  of  themselves  great  recommendations,  in  connexion  with 
its  softness,  lightness,  and  the  porosity  of  its  texture.  It  is 
sold  either  as  "carded  cotton,"  or,  in  the  form  of  " sheet 
cotton,"  in  large  sheets,  of  which  both  surfaces  are  smooth, 
more  or  less  glazed,  forming,  as  it  were,  thin  pellicles,  between 
which  the  true  cottony  mass  is  inclosed.  As  an  application 
to  secreting  surfaces,  it  will  be  found  to  be  less  absorbent  than 
lint,  and  probably  more  irritating.  It  is  very  much  employed 
as  a  covering  to  extensive  superficial  burns,  to  protect  their 
sensitive  surface  from  the  action  of  the  air  and  other  irritants. 
But  when  there  is  much  suppuration  or  other  discharge,  the 
cotton,  becoming  more  or  less  imbued  with  the  secretion,  is 
heavy  and  heating,  and  is  readily  displaced  by  slight  move- 
ments of  the  patient,  becoming  rolled  into  hard  masses. 
Probably  every  dresser  has  been  often  much  annoyed,  by  the 
difficulty  which  he  has  experienced  in  removing  from  a  large 
moist  sore,  these  numerous  indurated  pellets  of  cotton,  which 
sometimes  adhere  very  tenaciously  to  the  granulations.  Its 
chief  uses  —  and  for  these  it  is  almost  invaluable  —  are,  to 
form  a  soft  bed  in  which  an  injured  part  may  be  reposed,  to 
prevent  unpleasant  pressure  and  excoriation  from  bandages 
and  other  apparatus,  and  to  envelope  parts,  of  which  the 
natural  temperature  has  become  depressed. 

3.  Tow  is  never  applied  directly  to  a  secreting  or  abraded 
surface ;  being  too  harsh  and  irritating.     It  is  made  use  of 
in  enveloping  other  dressings  in  cases  of  profuse  discharges, 
as  in  compound  fractures,  suppurating  stumps,  &c. 

4.  The  COMPRESS  is  employed  for  a  variety  of  purposes. 


32  SURGICAL    DRESSINGS. 

As  the  name  imports,  it  was  at  first  used  to  effect,  or  to  fa- 
cilitate, pressure  upon  any  part ;  now,  however,  it  has  acquired 
a  wider  application,  being  equally  adapted  to  the  covering 
and  protection  of  injured  surfaces ;  to  retain  other  dressings, 
and  to  give  regularity  and  symmetry  to  the  form  of  a  limb, 
sr  of  any  other  part,  to  which  a  bandage  is  to  be  applied. 

Compresses  may  be  made  of  various  materials,  as  linen, 
muslin,  woollen  fabrics,  lint,  cotton,  tow,  &c.  When  intended 
for  direct  application  to  secreting  surfaces,  they  should  be 
of  lint  or  soft  linen,  and  applied  dry  or  anointed.  The  ad- 
vantages of  a  flannel  compress  are,  its  elasticity,  its  warmth, 
and  the  readiness  with  which  it  imbibes  any  moisture  of  the 
surface.  The  cheapness  of  the  different  fabrics  of  cotton 
recommends  them  for  many  purposes  ;  for  wherever  economy 
may  be  properly  consulted,  without  conflicting  with  more  im- 
portant considerations,  the  surgeon,  whether  in  hospital  or  in 
private  practice,  should  not  fail  to  be  influenced  by  it  in  the 
choice  of  the  material  for  his  dressings.  Whenever  a  com- 
press is  to  be  employed  external  to  other  dressings,  or  upon 
an  uninjured  surface,  it  may,  as  a  general  rule,  be  formed  of 
cotton  stuffs,  as  properly  as  of  linen. 

For  convenience,  accuracy,  and  neatness  of  application, 
compresses  are  made  of  divers  forms  and  shapes,  to  suit  par- 
ticular cases  and  indications ;  Velpeau's  division  is  a  very  sim- 
ple one,  into  the  plain,  the  divided,  and  the  folded.  The  most 
important  are,  the  square,  the  graduated,  the  perforated,  and 
the  split  compresses. 

The  square  compress  is  sufficiently  well  described  by  its 
name,  as  are  also  the  oblong  and  the  triangular  compresses ; 
their  size  and  thickness  may  vary  at  the  pleasure  of  the  sur- 
geon, and  with  the  requirements  of  each  case. 

The  graduated  compresses  are  so  contrived  as  that  they 
shall  present  a  gradually  diminishing  surface  at  the  summit, 
as  their  thickness  increases. 

The  common  graduated  compress  may  be  made  by  taking  a 
strip  of  any  material  of  the  required  width,  and  folding  it 
upon  itself  so  that  each  successive  fold  shall  be  shorter  than 
the  one  which  preceded  it.  By  thus  regulating  the  length  of 
the  folds  at  one  end  only,  the  single  graduated  compress  is 
made  (fig.  4) ;  by  pursuing  the  same  plan  at  both  extremities, 
the  double  graduated  compress.  The  pyramidal  compress  is 


SURGICAL    DRESSINGS. 


33 


FIG.  4. 


FIG.  5. 


formed  by  piling  successively  on  each  other  pieces  of  any  ma- 
terial, of  gradually  and  regularly  dimi- 
nishing size, — of  square,  oblong,  or  circu- 
lar shape  (fig.  5). 

These  varieties  of  the  compress  are 
useful  when  firm  pressure,  made  generally 
with  the  aid  of  a  bandage,  or  of  the  hand, 
is  required  upon  some  deep-seated  point, 
as,  for  example,  to  arrest  the  circula- 
tion through  a  bleeding  vessel. 

The  perforated  compress,  as  its  name 
indicates,  is  one  in  which  an  aperture  has 
been  cut.  The  number  of  such  aper- 
tures may  vary  indefinitely.  A  very  ele- 
gant dressing  to  a  suppurating  surface  consists  of  a  compress, 
or  a  simple  piece  of  linen,  perforated  in  a  cribriform  manner, 
and  spread  with  cerate  of  some  kind.  The  pus  has  in  this 
way  free  escape,  and  may  be  absorbed  by  lint  laid  upon  this 
sieve-like  covering. 

The  chief  varieties  of  the  split  compress,  are  the  retractor 
of  two  and  of  three  tails,  and  the  Malta  cross. 

The  retractors  are  formed  by  making  one  or  two  longitudi- 
nal slits  (as  two  or  three  tails  are  required)  in  a  piece  of  mus- 
lin three  or  four  inches  wide,  and  two  and  a  half  feet  long. 
They  are  used  in  amputations  to  draw  up  the  soft  parts,  after 
the  incision  has  been  made,  for  the  purpose  of  protecting  them 
from  the  saw,  while  the  bone  is  being  removed  as  high  up  as 
the  incision  of  the  soft  parts  will  allow.  The  retractor  of  two 
tails. is  employed  in  amputations  of  the  arm  and  thigh;  the 
other  in  the  removal  of  the  forearm  and  leg.  In  its  applica- 
tion, the  former  is  made  to  grasp  the  bone  between  its  tails, 
which  are  then  drawn  upwards  beneath  the  member,  the  body 
of  the  retractor  being  carried  in  the  same  direction  along  its 
superior  face ;  the  soft  parts  are  thus  enclosed  and  shielded 
between  the  two.  In  using  the  retractor  of  three  tails,  the 
middle  tail  is  thrust  between  the  two  bones  of  the  leg,  or  fore- 
arm. 

To  prepare  the  Malta  cross,  (fig.  6),  take  a  square  piece  of 
linen  or  patent  lint,  of  the  required  size,  and  fold  it  through 
the  middle  of  one  of  its  sides ;  double  the  oblong  thus  formed 
upon  itself  through  the  centre  of  one  of  its  longitudinal  dia- 


SURGICAL    DRESSINGS. 


FIG.  6. 


meters,  and  from  the  free  angle  of  the  smaller  square  thus 
produced,  (the  angle  at  which  the  vari- 
ous laminae  composing  the  square  are  se- 
parable), make  an  incision  along  its  ob- 
lique diameter,  to  within  a  short  dis- 
tance of  the  opposite  angle.  When  the 
square  is  re-opened,  it  will  present  the 
form  of  the  Malta  cross.  It  is  used  as 
a  direct  application  to  stumps,  having 
been  previously  perforated  at  numerous 
points,  and  spread  with  cerate. 

The  half  Malta  cross  is  made  by  fold- 
ing an  oblong  piece  of  linen,  or  patent 
lint,  through  the  middle  of  its  longitudi- 
nal diameter,  and  continuing  an  incision  from  one  of  its  free  an- 
gles, along  the  oblique  diameter,  nearly  to  the  opposite  angle. 
Its  uses  are  as  those  of  the  last  described. 

5.  SPONGE-TENT  is  prepared  by  thoroughly  saturating  soft 
sponge  with  melted  beeswax,  or  gum  tragacanth,  and  subject- 
ing it  to  pressure  as  it  cools.     It  is  employed  for  the  purpose 
of  dilating  wounds,  fistulous  canals,  &c.,  which  it  eifects  by 
imbibing  moisture  from  the  cavity,  and  thereby  swelling.     For 
use,  a  piece  of  the  hardened  mass  of  sponge  is  cut  of  the  re- 
quisite size  and  form,  and  gently  introduced  into  the  cavity, 
where  it  may  be  easily  confined  by  a  piece  of  adhesive  plaster 
stretched  across  the  orifice. 

It  is  well  to  recollect  that  the  prolonged  retention  of  a 
sponge-tent,  particularly  in  irritable  patients,  frequently  ex- 
cites violent  pain,  swelling,  and  heat  in  the  part,  accompanied 
often  with  considerable  fever.  In  such  cases,  these  eifects 
speedily  disappear  upon  the  removal  of  the  tent,  followed  or 
not  by  the  application  of  some  soothing  dressing,  as  warm 
water,  or  a  poultice. 

6.  SETONS  are  made  of  a  variety  of  materials :  as  of  a  skein 
of  silk,  a  piece  of  linen  tape,  or  a  piece  of  ordinary  soft  linen, 
which  has  been  unravelled  along  its  borders. 

7.  ADHESIVE  PLASTER,  is  composed  of  some  substance  or 
substances,  possessed  of  tenacious  or  adhesive  properties,  and 
susceptible  of  being  spread  upon  linen,  muslin,  or  some  similar 
material. 

The  "  emplastrum  resinse,"  of  the  U.  S.  Pharmacopoeia,  is 


SURGICAL    DRESSINGS.  35 

the  one  generally  employed  in  this  country.  It  is  sold  in  the 
shops  already  spread  upon  linen  or  muslin.  (The  adhesive 
plaster  made  by  Charles  Ellis,  of  this  city,  is  particularly  ex- 
cellent.) 

Adhesive  plaster  is  one  of  the  most  indispensable  articles  of 
dressing  to  the  surgeon.  Its  uses  are  numerous. 

Its  most  frequent  employment  is  in  the  approximation  of 
the  lips  of  wounds.  For  this  purpose,  the  plaster  should  be 
cut  into  strips,  varying  in  width  according  to  circumstances, 
but,  for  neatness-sake,  the  strips  intended  for  the  same  dress- 
ing should  be  of  equal  width.  In  cutting  them,  the  sheet  of 
plaster  should  be  made  tense  by  the  hands  of  the  surgeon  and 
an  assistant,  while  the  former  forces  a  pair  of  sharp  scissors, 
without  closing  the  blades,  across  the  sheet  parallel  with  the 
course  of  its  threads ;  in  this  way  the  strips  may  be  cut 
straight  and  very  rapidly. 

For  application,  the  strip  should  be  warmed,  by  being  held 
near  a  fire;  or,  which  is  much  better,  by  wrapping  its  un- 
spread  surface  around  a  vessel  containing  boiling  water ;  the 
wound  having  been  carefully  cleansed,  and  the  surrounding 
surface  washed  and  dried,  and  freed  from  hair,  one  extremity 
of  the  strip  is  placed  upon  the  skin  at  a  suitable  distance 
from  the  edge  of  the  wound, — the  distance  varying  according 
to  the  degree  of  force  which  shall  be  requisite  to  retain 
the  edges  in  contact, —  the  edges  themselves  are  accurately 
approximated  by  the  fingers  of  the  dresser,  and  the  strip  is 
drawn  across  them,  and  pressed  all  along  its  course  upon 
the  skin. 

If  the  wound  is  so  long  as  to  require  the  application  of  two 
or  more  strips,  spaces  should  be  left  between  them,  to  permit 
the  escape  of  fluid. 

The  length  of  time  during  which  the  plaster  should  remain 
must  vary  in  different  cases.  Generally,  the  strips  should  not 
be  disturbed  until  the  wound  has  cicatrized,  or  until  its  edges 
are  somewhat  firmly  agglutinated,  unless  they  shall  have  be- 
come previously  loosened  from  accidental  causes,  or  productive 
of  some  unpleasant  effect. 

In  removing  the  dressing,  the  portions  of  the  strip  on  each 
side  of  the  wound  should  be  raised  alternately,  and  fresh 
pieces  applied  as  soon  as  possible,  if  the  same  dressing  is  to 
be  continued.  Where  a  wound  is  traversed  by  more  than 


86  SURGICAL    DRESSINGS. 

one  strip,  a  fresh  one  should  take  the  place  of  each,  as  it  is 
removed,  before  a  second  is  withdrawn.  This  precaution  is 
necessary,  in  order  that  the  delicate  adhesions  of  the  lips  of 
the  wound  shall  not  be  destroyed  or  weakened. 

Many  years  ago,  Mr.  Baynton,  an  English  surgeon,  recom- 
mended the  employment  of  adhesive  plaster  in  the  treatment 
of  ulcers.  The  plaster  which  he  used  was  composed  of  six 
drachms  of  resin  melted  with  a  pound  of  lead  plaster.  He 
directed  that  the  ulcer  be  first  carefully  cleansed,  and  the 
surrounding  surface  denuded  of  hair ;  that  adhesive  strips, 
two  inches  wide,  and  of  sufficient  length  to  encompass  the 
limb,  and,  in  addition,  to  extend  four  or  five  inches  over  the 
edges  of  the  ulcer,  be  passed  around  the  leg,  from  an  inch 
below  to  two  or  three  inches  above  the  sore,  and  with  suffi- 
cient force  to  approximate  slightly  its  edges, — each  successive 
strip  being  in  contact  with  that  last  applied ;  that  compresses 
of  soft  calico  be  placed  around  the  limb,  and  the  whole  enve- 
loped with  a  bandage  from  the  toes  to  the  knee.  If  there 
should  be  much  heat  or  pain  in  the  limb,  cold  water  may  be 
applied  over  the  dressing.  This  treatment  is  best  adapted  to 
chronic  indolent  ulcers,  attended  with  swelling  and  induration 
of  the  limb.  As  the  tumefaction  abates,  the  dressings  are 
to  be  applied  more  tightly :  they  should  be  changed  more  or 
less  frequently,  according  to  the  greater  or  less  amount  of 
suppuration,  from  twice  in  twenty-four  hours,  to  once  every 
three  or  four  days.  According  to  the  experiments  of  Velpeau, 
Boyer,  Roux,  and  others,  ulcers  are  cured  more  speedily  by 
this  method  of  treatment  than  by  any  other ;  walking  about 
on  the  limb,  moderately,  facilitates  the  cure.  Boyer  found 
that  the  average  length  of  treatment  by  this  mode,  calculated 
from  a  large  number  of  cases,  was  twenty-six  days ;  while,  ac- 
cording to  Duchatelet,  of  690  cases  treated  by  the  ordinary 
methods,  the  average  duration  of  treatment  was  fifty-two  and 
a  half  days.  (Cutler,  pp.  210,  211.) 

The  ordinary  adhesive  plaster  of  the  shops  will  very  well 
answer  the  purpose  of  that  employed  by  Baynton.  Previous 
to  its  application,  the  limb,  from  the  toes  to  within  a  few 
inches  of  the  ulcer,  should  be  enveloped  by  a  roller,  which  is 
to  be  continued  over  the  whole  leg  after  the  other  dressings 
have  been  applied. 

In  the  drawing,  fig.  40,  this  method  of  treatment  is  illus- 


SUKQICAL    DRESSINGS. 


3T 


trated,  the  upper  part  of  the  ulcer  being  purposely  left  ex- 
posed. 

The  same  plan  of  treatment  has  been  extended,  by  Vel- 
peau,  Boyer,  and  Roux,  to  all  ulcers  which  have  become 
atonic  or  chronic,  and  by  the  former  of  these  distinguished 
surgeons,  particularly,  to  burns  (Yelpeau,  He'd.  Ope'rat., 
vol.  i.,  p.  257),  and  also  to  varicose  and  ganglionary  tumours, 
&c.,  &c. 

M.  Fricke,  of  Hamburgh,  first  called  attention  to  the  effi- 
cacy of  compression,  methodically  and  carefully  made  by 
strips  of  adhesive  plaster,  in  the  treatment  of  epididymitis. 
They  may  be  thus  applied :  the  scrotum  should  be  carefully 
cleansed,  and  the  hair  shaved  from  it;  the  testicle  is  then 
forced  to  the  bottom  of  the  sac,  and  the  affected  side  of  the 
scrotum,  clasped  just  below  the  ring  by  the  thumb  and  fore- 
finger of  the  left  hand,  is  surrounded  by  a  very  narrow  strip 
of  plaster,  which  is  then  carried  down  over  the  scrotum  in 
such  a  way  as  to  apply  itself  neatly  and  smoothly  to  the 
skin ;  successive  strips  are  used,  until  the  part  is  entirely  en- 
veloped. The  pressure  should  be  moderate  and  regular.  As 
the  swelling  subsides,  the  strips  will  of 
course  become  loose,  when  they  may  be  re- 
moved, and  fresh  ones  applied  as  before. 
If  there  be  much  pain,  the  employment  of 
the  adhesive  plaster  may  be  preceded  by  the 
application  of  leeches  over  the  scrotum  it- 
self, or  in  the  groin. 

Chronic  indurations  generally  of  the 
testicle  are  very  often  removed  or  dimi- 
nished by  this  treatment.  The  annexed 
drawing  illustrates  this  application  (fig.  7). 

It  will  frequently  be  found  that,  after 
the  removal  of  adhesive  strips  from  the 
surface  of  the  body,  a  portion  of  the  ad- 
hesive matter  remains  upon  the  skin ; 
water  alone  will  not  easily  remove  it,  but 
gentle  rubbing  with  a  sponge  moistened 
with  spirit  of  turpentine,  will  readily 
cleanse  the  part.  The  black  discoloration 
often  noticed  is  a  matter  of  no  consequence ;  it  is  simply  owing 


FIG. 


38  SURGICAL    DRESSINGS. 

to  the  action  of  the  matter  of  the  secretions  of  the  surface 
upon  the  lead  plaster. 

Several  objections  have  been  urged  against  the  employ- 
ment of  the  common  adhesive  plaster  ;  some  of  them  are  well 
founded,  others  not  so.  It  sometimes,  though  by  no  means 
usually,  irritates  the  skin,  producing  an  erythematous  inflam- 
mation, and  occasionally  a  papular  or  a  vesicular  eruption ; 
this  is  particularly  the  case  when  the  application  is  made  to 
the  skin  of  young  children  and  infants.  «To  avoid  such  in- 
conveniences, the  "isinglass  plaster"  has  been  recommended 
as  a  substitute  for  the  other.  It  is  prepared  by  spreading 
upon  oiled  silk,  or  silk  glazed  on  one  side  only,  and  on  the 
unglazed  side,  a  solution  of  Isinglass  in  Spirit  (Listen).  When 
dry,  the  silk  may  be  laid  aside  until  required  for  use,  then  it 
is  cut  into  strips  of  the  desired  width,  and  its  adhesive  sur- 
face softened  by  the  application  to  it  of  a  hot  moist  sponge ; 
the  strips  are  to  be  employed  as  directed  for  the  ordinary 
adhesive  plaster.  The  advantages  of  this  preparation  are, 
its  cleanliness,  its  perfectly  unirritating  nature,  and  its  trans- 
parency, whereby  the  surgeon  is  enabled  to  see  the  condition 
of  the  surface  upon  which  it  is  applied,  without  removing 
the  strips.  It  is,  however,  less  adhesive  than  the  common 
plaster;  for,  as  has  been  well  observed  by  Dr.  Smith 
("  Minor  Surgery,"  p.  38),  the  warm  discharges  from  the 
part  to  which  the  isinglass  plaster  is  applied,  soften  its  mate- 
rial, as  did  the  hot  moist  sponge.  Therefore,  whenever  con- 
siderable tenacity  of  adhesion  is  requisite,  the  ordinary  plaster 
is  preferable. 

(The  isinglass  plaster  is  made  in  this  city  by  Mr.  Hus- 
band, Apothecary,  Spruce  Street.) 

"  COLLODION,"  an  ethereal  solution  of  gun-cotton,  will  be 
found  to  be  a  very  convenient  adhesive  material.  To  apply 
it,  lay  strips  of  muslin  or  linen  across  the  wound,  the  edges 
of  the  latter  having  been  accurately  approximated,  and  satu- 
rate them  with  the  collodion  by  the  aid  of  a  camel's-hair 
pencil.  The  strips  should  be  made  of  some  unglazed  fabric, 
as  this  imbibes  the  solution  more  readily  and  thoroughly  than 
the  glazed. 

In  slight  wounds  the  strips  may  even  be  dispensed  with, 
the  liquid  being  merely  painted  over  the  surface,  the  edges 
t>f  the  wound  being  held  together  until  the  collodion  is  dry. 


SURGICAL    DRESSINGS.  39 

The  contractility  of  this  substance  is  such  that  it  has  been 
recommended  as  a  means  of  curing  small  ncevi,  by  the  com- 
pression which  it  induces  in  drying. 

Various  other  plasters  are  frequently  employed  by  the 
surgeon. 

The  soap  plaster — "  Emplast.  Saponis," — spread  upon  soft 
sheepskin,  and  then  cut  into  strips,  or  into  pieces  of  any 
shape  and  size,  will  be  found  oftentimes  to  answer  a  very  ad- 
mirable purpose,  in  making  pressure  upon  an  enlarged  joint, 
or  an  indolent  tumour,  &c.,  &c.  It  is  very  mild  and  unirri- 
tating,  and  preserves  the  integuments  soft  and  moist,  and  is 
an  excellent  preventive  of  excoriation. 

The  mercurial  plaster  is  very  commonly  employed  as  a  re- 
solvent of  tumours,  and  other  indurations.  The  belladonna 
plaster  is  an  excellent  anodyne  application. 

Plasters  should  be  smoothly  and  evenly  spread  on  coarse 
muslin,  or  stiff  brown  paper,  or,  which  is  much  the  best  ma- 
terial, on  soft  sheepskin.  A  piece  of  skin,  or  other  material, 
should  be  cut  of  a  shape  suitable  for  application  to  each  par- 
ticular part,  and  rather  larger  than  the  surface  intended  to 
be  covered  by  the  plaster ;  a  narrow  strip  of  paper  may  be 
then  pasted  around  its  margin,  and  within  the  space  thus 
bounded,  the  plaster  is  to  be  spread,  after  which  the  paper 
may  be  removed.  In  order  that  it  may  adapt  itself  smoothly, 
accurately,  and  neatly  to  the  surface,  it  is  well  to  make 
several  slits  from  the  margin  of  the  plaster  towards  its  centre. 

8.  One  of  the  most  common  articles  of  dressing,  both  in 
domestic  and  professional  practice,  is  the  POULTICE.  When 
badly  made,  it  is  undoubtedly  deserving  of  the  abomination, 
with  which  it  is  so  amusingly  and  feelingly  regarded  by  Mr. 
Liston;  but  when  properly  prepared,  and  correctly  used,  it 
cannot,  we  think,  be  conveniently  dispensed  with  for  any 
other  substitute  whatever. 

The  poultice  should  be  always  soft  and  moist,  and  these 
requirements  should  be  kept  in  view,  as  far  as  possible,  in 
the  choice  of  the  materials  of  which  it  is  to  be  made.  The 
substance  which  is  to  form  its  basis  is  generally  in  the  form 
of  a  powder  ;  this  should  be  stirred  about  with  sufficient  water 
to  give  to  the  mass  a  soft  consistence,  yet  not  so  moist  as  to 
permit  the  fluid  to  flow  from  it.  The  water  may  be  cold  or 
hot,  according  to  circumstances,  and  may  be  best  incorpo- 


40  SURGICAL    DRESSINGS. 

rated  with  the  powder  by  adding  small  portions  of  each  al- 
ternately and  successively.  The  semi-solid  mass  thus  pre- 
pared may  be  spread  upon  a  piece  of  muslin  smoothly  and 
evenly,  by  the  aid  of  a  wooden  or  iron  spatula,  or  an  ordinary 
table-knife ;  it  should  be  from  a  fourth  to  half  an  inch  -thick, 
and  occupy  just  so  much  of  the  surface  of  the  muslin  as  that 
the  margin  of  the  latter  may  be  reflected  upon  it,  all  around, 
for  the  space  of  half  an  inch ;  this  latter  arrangement  gives 
to  the  poultice  a  very  neat  and  elegant  appearance,  and  fa- 
cilitates very  much  its  removal  from  the  surface  to  which  it 
may  have  been  applied. 

Some  surgeons  prefer  to  protect  the  part  from  immediate 
contact  with  the  poultice,  by  the  intervention  of  a  piece  of 
fine  cambric  or  gauze,  previously  laid  upon  the  surface  of 
the  latter.  For  so  doing,  they  urge  that,  otherwise,  portions 
of  the  poultice  remain  adherent  to  the  skin  or  ulcer,  after 
the  mass  has  been  removed,  and  are  displaced  with  some  dif- 
ficulty and  occasional  pain  to  the  patient.  If,  however,  the 
poultice  has  been  properly  prepared  and  applied,  and  not  too 
long  retained,  this  annoyance  will  rarely  occur.  Moreover, 
by  thus  covering  the  poultice,  we  are  deprived,  in  a  great 
measure,  of  the  benefit  derivable  from  the  direct  contact  of 
its  materials  with  the  aifected  part ;  and  this  consideration  is 
an  important  one  oftentimes,  as,  for  example,  when  the  poul- 
tice is  medicated;  for,  as  Velpeau  remarks,  "poultices  are 
not  intended  to  act  merely  as  compresses  saturated  with  warm 
water."  Yet  when  the  application  is  intended  for  the  eye, 
or  the  neighbourhood  of  the  nostrils  or  mouth,  or  when  it 
contains  ingredients  which  may  be  too  irritating  for  the  sound 
skin,  it  is  very  proper  to  use  the  precaution  alluded  to. 

Generally,  the  smearing  of  the  poultice  with  oil,  or  grease 
of  any  kind,  is  unnecessary  and  objectionable. 
i  In  order  to  retain  the  warmth  and  moisture  and  softness  of 
'the  poultice  as  long  and  as  completely  as  possible,  it  should 
j  always  be  covered  externally  with  a  piece  of  oiled  silk,  or  thin 
India-rubber  cloth ;  the  unpleasant  odour  of  the  latter,  how- 
ever, renders  the  first  a  preferable  application. 

This  dressing  should  be  changed  at  least  twice  daily;  and 
when  the  discharge  is  profuse,  in  warm  seasons,  when  the 
poultice  is  very  soon  soured — or  when  the  speedy  production 
of  suppuration,  or  the  relief  of  great  pain  is  desired,  the  ap- 


SURGICAL    DRESSINGS. 


41 


plications  should  be  renewed  as  often  as  every  two  or  three 
hours,  or  even  still  more  frequently. 

In  removing  it,  the  poultice  should  be  gently  drawn  up  by 
one  side,  and  reflected  upon  itself  gradually,  until  the  whole 
is  lifted  up ;  if  it  adhere  at  any  point,  its  detachment  will  be 
easily  effected  by  allowing  a  little  warm  water  to  trickle  over 
the  part ;  before  applying  a  fresh  dressing,  the  surface  should 
be  carefully  and  gently  cleansed. 

To  retain  the  application  in  its  place,  a  roller  may  be  passed 
around  it,  extending  a  short  space  both  above  and  below  it. 
But  it  often  occurs  that  the  part  to  which  the  poultice  is  ap- 
plied, whether  it  be  an  irritable  ulcer  or  otherwise,  is  too  ten- 
der and  painful  to  bear  the  agitation  to  which  it  must  be  sub- 
jected in  the  use  of  the  roller ;  in  such  cases  the  "  bandage 
of  Scultetus"  should  be  employed;  thus,  the  entire  dressing 
may  be  renewed  without  moving  the  suffering  part. 


FIG.  8. 


FIG.  9. 


Dr.  Hays,  of  this  city,  is  in  the 
habit  of  making  use  of  a  bandage, 
in  similar  cases,  which  may  be  con- 
sidered as  a  modification  of  the 
many-tailed  bandage ;  its  simplicity 
and  perfect  adaptation  to  this  and 
numerous  other  analogous  pur- 
poses, renders  it  worthy  of  descrip- 
tion. 

A  piece  of  muslin  more  than 
wide  enough  to  envelope  the  part, 

as  the  leg,  for  instance,  and  rather 
4* 


42  SURGICAL    DRESSINGS. 

longer  than  the  poultice,  or  other  application  which  it  is  in- 
tended to  retain,  is  cut  or  torn,  transversely  from  each  mar- 
gin, leaving  a  central  space  entire,  of  some  few  inches  in 
breadth ;  this  is  laid  on  the  pillow  or  bed,  and  the  leg,  with 
the  poultice  applied,  is  placed  upon  it ;  then,  commencing 
from  below,  the  tails,  first  on  one  side  and  then  on  the  other, 
are  alternately  and  successively  brought  over,  as  the  strips  of 
the  bandage  of  Scultetus,  and  the  last  two  tied  in  a  single  or 
double  bow-knot.  This  simple  bandage  will  be  found  very 
useful  in  retaining  blisters,  cerates,  or  any  similar  application, 
upon  parts  too  sensitive  to  admit  of  much  disturbance  :  figs. 
8,  9,  exhibit  this  bandage,  free,  and  applied. 

If  the  discharge  is  at  all  profuse,  it  should  be  absorbed  as 
soon  as  possible  by  cotton,  tow,  or  some  similar  substance, 
arranged  to  receive  it.  Thus  if  the  arm  be  the  part  affected, 
it  should  be  laid  upon  a  pillow  (the  patient  being  in  bed),  pro- 
tected by  a  piece  of  oil-cloth,  upon  which  some  tow  or  bran 
has  been  placed ;  the  same  disposition  may  be  made  with  the 
leg ;  or  this  member  may  be  conveniently  put  in  a  fracture- 
box  filled  with  bran,  or  containing  a  pillow  protected  as  be- 
fore. In  order  to  preserve  the  bed-clothes  from  contact  with 
the  discharged  matter,  a  semi-circular  framework  of  wire  or 
bamboo,  should  be  thrown  over  the  limb.  (See  fig.  10.) 

The  material  of  which  the  poultice  shall  consist  must  vary 
with  the  indications  to  be  fulfilled  in  each  case.  It  may  be 
emollient,  refrigerant,  astringent,  stimulating,  or  anodyne. 

The  emollient  poultice,  as  its  name  implies,  is  made  of  per- 
fectly bland  and  unirritating  material.  The  materials  of 
which  it  is  usually  prepared,  are  bread  and  milk,  bread  and 
water,  and  water  with  corn-meal,  flaxseed  meal,  or  slippery 
elm  powder.  Each  surgeon,  probably,  has  some  fancy  of  his 
own  with  regard  to  what  forms  the  best  poultice,  some  pre- 
ferring this,  some  that  material.  Abernethy,  who  seems  pro- 
foundly to  have  studied  the  philosophy  of  poultices,  gives 
decided  preference  to  the  bread  and  water,  and  the  flaxseed 
meal  poultices ;  after  detailing  the  mode  in  which  the  latter 
should  be  prepared,  he  exclaims,  rapturously:  "When  thus 
made,  oh !  it  is  beautifully  smooth  ;  it  is  delightfully  soft ;  it  is 
warm  and  comfortable  to  the  feelings  of  the  patient."  (South's 
"  Hints  on  Emergencies,"  p.  12.) 

The  bread  poultices,  made  either  with  milk  or  water,  be- 


SURGICAL    DRESSINGS.  43 

come  dry  and  stiff  sooner  than  those  prepared  with  flaxseed 
meal ;  the  latter  contains  a  considerable  portion  of  oil,  which 
imparts  great  softness  to  the  mass  when  wet ;  but  it  also  gives 
it  a  not  very  pleasant  odour,  and  in  warm  weather,  or  when 
long  in  contact  with  an  inflamed  surface,  it  soon  becomes 
rancid  and  irritating;  upon  some  skins,  moreover,  it  pro- 
duces a  vesicular  eruption.  Perhaps  the  poultice  least  lia- 
ble to  objection,  is  that  made  of  the  powder  of  slippery  elm 
bark. 

The  above-named  poultices  when  applied  cold  may  be 
termed  refrigerant.  An  application  of  this  kind  may  be 
prepared  by  employing  a  solution  of  acetate  of  lead,  in  the 
proportion  of  3ij.  or  3iij.  to  a  pint  of  water,  instead  of  simple 
water,  in  mixing  the  poultice.  In  order  to  increase  their 
cooling  effect,  they  may  be  applied  without  covering  them 
with  oiled  silk  or  any  bandage,  so  that  evaporation  shall  be 
unchecked.  It  must  be  recollected,  however,  that  although 
cold  when  first  laid  upon  the  part,  they  soon  acquire  the  same 
temperature  as  the  surface ;  they  require,  therefore,  frequent 
renewal. 

Astringent  poultices  may  be  made  by  incorporating  any 
powder  of  astringent  property,  with  some  one  of  the  mate- 
rials already  mentioned.  The  substances  most  frequently 
used  are  powdered  oak  bark,  galls,  and  alum.  A  very  elegant 
poultice  of  this  kind  is  prepared  by  rubbing  up  alum  with  the 
white  of  egg. 

Stimulating  poultices  are  formed  in  the  same  way,  by  in- 
corporating stimulating  substances  with  some  sort  of  meal, 
and  water.  With  this  view  the  scrapings  of  carrot,  or  horse- 
radish, are  employed.  Solutions  of  chloride  of  lime,  or  of 
soda,  of  creasote,  or  of  common  soap,  are  often  used ;  or  a 
poultice  may  be  made  of  stewed  onions.  One  of  the  best 
and  most  agreeable  of  the  stimulating  poultices  is  the  cam- 
phor poultice,  made  by  incorporating  spirits  of  camphor  with 
^the  meal  or  other  substance  used  as  the  basis.  It  is  particu- 
larly serviceable  as  an  application  to  gangrenous  parts,  slough- 
ing ulcers,  &c. 

The  fermenting  poultice  is  made  by  incorporating  yeast,  or 
porter,  with  corn  meal,  and  is  of  great  advantage  in  hastening 
the  separation  of  gangrenous  parts.  A  very  common  prepa- 
ration of  this  sort  is  the  ordinary  mustard  poultice.  These 


44  SURGICAL    DRESSINGS. 

applications  are  employed  when  a  decided  irritant  or  stimu- 
lating effect  is  indicated. 

An  anodyne  poultice  may  be  made  by  stewing  bruised 
poppy-heads  until  they  become  somewhat  soft  and  adhesive; 
or  the  dregs  of  opium,  left  after  the  preparation  of  laudanum, 
or  this  liquid  itself,  may  be  mixed  with  meal ;  or  the  bruised 
leaves  of  belladonna  may  be  moistened,  and  applied.  The 
leaves  of  the  tobacco  plant  moistened,  may  be  used  in  the 
same  way,  but  their  application  should  be  carefully  watched, 
lest  too  great  prostration  ensue.  Hops,  or  chamomile- 
flowers,  enclosed  in  a  flannel  bag  wrung  out  of  hot  water,  or 
incorporated  with  meal  or  bran  and  hot  water,  form  an  ex- 
cellent anodyne  poultice. 

Medicated  poultices  may  be  very  elegantly  prepared,  by 
making  an  infusion  of  the  substance,  whatever  it  be,  which 
has  been  selected  as  a  medicament.  Poppy-heads,  the  carrot, 
potato,  horseradish,  various  astringent  substances,  may  be 
simmered  for  an  hour  or  two  in  a  closed  vessel  containing 
water,  and  the  liquor,  after  having  been  strained,  incorporated 
with  meal  of  some  kind.  (South,  p.  11.) 

Mr.  Liston,  and  some  others,  object  altogether  to  the  use 
of  poultices,  proposing  to  substitute  water,  medicated  or 
simple,  cold  or  warm.  For  this  purpose,  some  one  of  the 
infusions  above  mentioned  will  answer  very  well.  They  should 
be  applied  by  means  of  linen,  lint,  or  flannel,  several  times 
folded,  and  saturated  with  them,  thus  constituting  fomenta- 
tions ;  they  should  be  kept  constantly  upon  the  part.  To  be 
of  real  benefit,  their  employment  demands  assiduous  and  un- 
intermitting  care  from  the  attendants,  much  more,  indeed, 
than  can  be  generally  expected  or  obtained,  particularly  in 
hospitals ;  this  constitutes  a  serious  objection  to  their  being 
generally  used  as  substitutes  for  poultices.  Neither  do  they 
supply  the  same  body  of  heat  as  the  latter,  when  heat  is  re- 
quired. They  are,  however,  more  cleanly  than  the  poultice, 
and  this  seems  to  be  their  chief  advantage — an  important  one 
truly.  Where  a  cold  application  of  this  sort  is  desired  to 
reduce  the  temperature  of  a  part,  the  most  effectual  is 
pounded  ice,  with  which  a  bladder,  or  a  bag  of  India-rubber 
cloth,  may  be  partially  filled :  the  temperature  of  the  appli- 
cation will  remain  as  low  as  32°  F.,  so  long  as  any  particle 
of  ice  remains  unmelted,  after  which  the  water  in  the  sac  will 


SURGICAL    DRESSINGS.  45 

gradually  acquire  the  temperature  of  the  part  to  which  it  is 
applied;  hence  the  bag  must  be  examined  from  time  to  time, 
and  the  ice  renewed  when  necessary.  Sacks,  intended  ex- 
pressly to  hold  water,  are  made  of  thin  India-rubber  cloth ; 
one  of  these  may  be  partially  filled  with  water  containing 
various  saline  substances  which,  during  their  solution,  ab- 
stract its  heat ;  this  forms  a  very  good  substitute  for  the 
bladder  of  ice,  when  ice  cannot  be  obtained.  One  ounce  of 
nitre,  one  ounce  of  sal  ammoniac  (chloride  of  ammonium), 
and  half  a  pint  of  water,  may  be  thus  employed.  (Thomson, 
"  Management  of  the  Sick  Room,"  p.  277.) 

These  applications,  whether  used  in  the  form  of  poultice 
or  of  fomentation,  fulfil  a  variety  of  indications.  When 
employed  warm,  they  relieve  spasmodic  pain,  or  sometimes 
continued  pain  ;  produce  or  promote  suppuration ;  allay  irri- 
tation frequently,  and  sometimes  inflammation :  diminish  oede- 
matous  enlargements,  by  promoting  local  perspiration,  or 
transpiration  ;  induce  resolution  of  acute  or  chronic  inflamma- 
tions and  indurations,  &c.,  &c.  When  cold,  they  are  more 
directly  sedative,  and  are  generally  used  to  subdue  inflamma- 
tion, or  to  overcome  muscular  action,  or  the  tonic  rigidity  of 
tissues,  as  in  the  reduction  of  hernia.  It  must,  however,  be 
borne  in  mind,  that  the  effects  of  these  applications  vary 
much  in  different  individuals ;  thus  in  some,  a  warm  poultice 
or  fomentation,  will  resolve  a  phlegmon  which  presents,  as 
nearly  as  can  be  judged,  the  same  condition  as  one  which, 
in  other  individuals,  is  most  relieved  by  cold.  The  feelings 
of  the  particular  patient  should  be  consulted,  to  enable  the 
surgeon  to  determine  when  one  mode  of  treatment  should  be 
substituted  for,  or  even  be  used  instead  of,  the  other. 

In  enumerating  the  circumstances  to  which  these  dressings 
are  particularly  applicable,  it  is  hardly  necessary  to  remark 
that  the  substances  with  which  they  may  be  medicated  will 
modify  accordingly  their  general  action. 

Within  the  last  two  or  three  years,  an  article  of  English 
manufacture,  called  "Spongio-Piline"  has  been  introduced 
to  the  notice  of  the  Profession,  and  recommended  by  the  sur- 
gical staffs  of  several  of  the  London  Hospitals.  It  is  also 
used  to  a  considerable  extent  in  the  Massachusetts  Genera' 
Hospital,  in  Boston,  and  perhaps  elsewhere  in  our  own 
country. 


46  SURGICAL    DRESSINGS. 

It  is  in  sheets,  three-fourths  of  an  inch  to  an  inch  in  thick- 
ness, looking  very  much  like  a  smoothly-cut  slice  of  sponge, 
one  surface  being  covered  with  a  sort  of  glazing  of  India- 
rubber. 

*  It  imbibes  water  very  freely,  and  the  glazed  surface  pre- 
vents evaporation,  as  a  piece  of  oiled-silk  when  laid  upon  a 
poultice.  When  wet  it  is  not  too  heavy  to  be  comfortable. 
The  advantages  claimed  for  it  are  its  durability,  its  capability 
of  being  washed,  and  thus  answering  for  different  patients ; 
and  its  cheapness,  as  compared  with  the  cost  of  the  materials 
of  which  poultices  are  made,  or  of  those  used  in  the  prepara- 
tion of  fomentations;  it  being  remembered  that  the  same 
piece  of  Spongio-Piline  will  last,  as  it  is  said,  a  very  consi- 
derable time,  and  be  serviceable  to  a  number  of  patients. 
This  last  claimed  advantage  is,  we  think,  of  questionable 
reality ;  for  there  would  certainly  be,  to  say  the  least,  great 
probability  that  by  thus  preserving  a  piece  of  dressing  as  a 
sort  of  heir-loom,  various  inconveniences  and  dangers  would 
arise  from  the  transference  from  person  to  person  of  irritating, 
offensive,  or  inoculable  matters.  To  furnish  a  piece  of  fresh 
"Spongio-Piline"  to  each  hospital-patient  who  required  an 
emollient  application,  would  be  a  very  expensive  charity. 
Having,  by  way  of  experiment,  applied  a  piece  of  this  article, 
saturated  with  warm  water,  to  our  own  person,  we  confess 
that  the  effect  was  less  agreeable  than  that  produced  by  a 
well-made  poultice  or  a  fomentation. 

9.  LOTIONS  are  composed  of  water  variously  medicated. 
They  are  usually  applied  upon  some  soft  porous  material, 
as  lint  or  folded  linen  ;  they  may  be  used  tepid  or  cold  ;  in  the 
choice  of  temperature,  the  feelings  of  the  patient  may  be  very 
properly  appealed  to  by  the  surgeon.  If  a  refrigerant  effect 
is  desired  from  the  wash,  it  should  be  applied  upon  a  single 
fold  of  lint,  or  linen,  and  left  exposed,  or  but  slightly  protected, 
so  that  evaporation  may  not  be  interfered  with ;  where  such 
an  action  is  not  called  for,  several  folds  of  the  porous  sub- 
stance should  be  laid  upon  the  part  and  covered  by  a  piece  of 
thin  oiled-silk — the  whole  to  be  retained  in  the  manner  alluded 
to  with  regard  to  the  poultice. 

As  a  general  rule,  lotions  should  be  employed  preferably 
to  cerates,  as  being  more  cleanly,  and  not  liable  to  become 


SURGICAL    DRESSINGS.  47 

^rritating  from  high  temperature  of  the  part,  or  season  of 
the  year. 

Formulae  for  several  lotions  will  be  found  at  the  end  of  the 
volume,  with  the  uses  of  each. 

10.  "  CERATES  are  unctuous  substances,  consisting  of  oil 
or  lard  perfectly  fresh  and  sweet,  united  with  wax,  sperma- 
ceti, or  resin,  to  which  various  medicaments  are  frequently 
added.    Their  consistence,  which  is  intermediate  between  that 
of  ointments  and  of  plasters,  is  such  that  they  may  be  spread 
at  ordinary  temperatures  upon  linen  or  leather,  by  means  of 
a  spatula,  and  do  not  melt  or  run  when  applied  to  the  skin." 
(U.  S.  Dispensat.)     They  are  used  as  applications  to  abraded 
or  ulcerated    surfaces,  and   their   composition  is  varied  for 
adaptation  to  each  case. 

11.  "  OINTMENTS  are  fatty  substances,  of  the  consistence 
of  butter,  such  that  they  may  be  readily  applied  to  the  skin 
by  inunction."     (U.  S.  Disp.)     They  are    simple,    or   com- 
posed of  various  medicaments.     The  ointments,  as  well  as  the 
cerates,  are  easily  affected  by  a  high  temperature,  becoming 
rancid  and  unfit  for  use.    They  are  usually  applied  upon  the 
sound  skin. 

A  number  of  ointments  and  cerates,  such  as  have  been 
found  useful,  are  given  at  the  end  of  the  book,  with  their  par- 
ticular applications. 

12.  LINIMENTS  are  intended  for  application  to  the  unbroken 
surface,  by  friction  with  the  hand,  or  soft  flannel.     Oil  should 
constitute  the  basis  of  the  liniment,  and  with  it  may  be  con- 
joined a  variety  of  modifying  ingredients,  so  that  it  may  be 
rendered  soothing,  or  irritating,  as  required. 

The  reader  will  find  formulae  for  the  preparation  of  many 
very  serviceable  liniments,  at  the  latter  end  of  the  volume. 

13.  The  SPONGE,  though  it  is  not  chiefly  used  as  an  article 
of  dressing  in  surgery,  is  of  such  essential  importance  to  the 
surgeon,  that  a  few  words  concerning  it  will  be  proper. 

The  common  sponge,  as  found  in  the  shops,  is  too  full  of 
gritty  particles  to  be  fit  for  surgical  purposes.  It  may  be 
sufficiently  well  prepared  for  ordinary  uses,  such  as  the 
cleansing  of  uninjured  surfaces,  by  maceration  in  boiling 
water,  and  subsequent  beating,  until  the  sabulous  or  calcareous 
particles  are  generally  removed.  But  for  nice  purposes,  as 
the  washing  of  inflamed  or  ulcerated  surfaces,  still  farther 


48  SURGICAL    DRESSINGS. 

preparation  is  requisite ;  after  having  been  treated  as  above, 
it  should  be  macerated  in  water  acidulated  with  about  one- 
thirtieth  of  its  bulk  of  chlorohydric  acid ;  dried  and  beaten 
again,  and  then  bleached  by  exposure,  when  moist,  to  the 
vapour  of  chlorine,  or  some  other  decolorizing  agent.  It  is 
now  soft  and  clean. 

Bandages  and  the  variety  of  apparatus  employed  in  the 
treatment  of  surgical  diseases  and  injuries,  will  be  considered 
hereafter. 


CHAPTER  III. 

GENERAL  RULES  FOR  DRESSING. 

IF  a  surgeon  is  called  upon  to  attend  to  an  injury  just 
occurred,  he  should  take  a  rapid,  yet  careful,  observation  of 
the  patient,  in  order  to  ascertain  the  condition  of  his  strength 
and  mental  functions,  and  to  discover  if  there  be  any  circum- 
stances calling  for  prompt  attention  previous  to  the  systematic 
application  of  a  dressing.  Thus,  if  there  be  much  prostra- 
tion present  from  any  cause,  fresh  air  and  cold  water  should 
be  freely  employed  to  revive  the  patient ;  or  a  little  wine  and 
water,  with  or  without  laudanum,  should  be  administered; 
and  all  obstacles  to  free  respiration,  such  as  a  cravat,  a  tight 
vest,  pressure  around  the  abdomen  from  tight  pantaloons, 
should  be  at  once  removed.  If  there  be  an  external  wound, 
it  should  be  immediately  examined,  and  prompt  measures  taken 
to  arrest  hemorrhage,  if  any  exist. 

As  soon  as  these  preliminaries  have  been  attended  to,  the 
surgeon  may  proceed  to  the  regular  application  of  the  dress- 
ing, as  in  an  ordinary  case  where  no  such  emergencies  present 
themselves. 

Having  first  arranged  such  articles  of  dressing  as  are 
likely  to  be  needed  in  the  case  under  consideration,  and  con- 
veniently disposed  of  the  necessary  instruments,  (all  useless 
display  being  avoided,  as  being  not  only  uncalled  for,  but 
positively  annoying  to  the  patient,) — and  having  at  command 
sponges  and  towels,  and  one  or  two  basins  of  warm  water, 
the  surgeon  should  expose  the  diseased  or  injured  part.  In 
doing  this,  great  care  and  the  utmost  gentleness  should  be 
observed ;  if  the  patient  be  dressed,  and  the  affected  part, 
as,  for  example,  the  arm  or  leg,  be  very  sensitive  and  painful, 
the  clothes  should  be  removed  by  ripping  them  along  a  seam, 
rather  than  be  drawn  off  in  the  usual  manner ;  and  any  ap- 
plication which  may  have  already  been  made  must  be  with- 
drawn with  the  same  care,  so  as  not  to  inflict  any  unnecessary 
suffering. 

5  (49) 


50  GENERAL    RULES    FOR    DRESSING. 

The  affected  part  and  the  surrounding  surface  should  now 
be  cleansed  as  perfectly  as  can  be  effected,  without  too  much 
pain,  by  means  of  a  sponge  and  castile-soap  and  water ;  in  ad- 
dition, if  there  be  a  wound,  or  if  it  be  deemed  advisable  to  ap- 
ply adhesive  plaster,  the  surface  should  be  denuded  of  hair, 
either  by  using  a  razor,  or,  which  will  answer  equally  well,  a 
sharp  scalpel. 

If  there  be  hemorrhage  to  any  notable  amount,  it  should  be 
arrested  at  once,  by  means  of  ligature  or  the  application  of 
cold,  or  some  styptic  ;  or  if  it  be  very  slight,  a  momentary  ex- 
posure to  the  air  may  control  it ;  or,  finally,  the  surgeon  may 
trust  for  its  arrest  to  the  pressure  of  the  dressing  which  he  is 
about  to  apply. 

In  the  choice  of  the  latter,  the  surgeon  will,  of  course,  con- 
sider the  indication  to  be  fulfilled  in  each  particular  case  as 
of  paramount  importance  ;  but  it  should  also  be  borne  in  mind 
that,  lightness,  freedom  from  any  undue  heating  qualities,  and 
cleanliness,  are  also  essential  to  the  perfection  of  a  dressing. 
The  retaining  bandage  should  be  such  as  may  be  applied  and 
removed  with  as  little  difficulty  and  annoyance  to  the  patient 
as  is  consistent  with  its  special  object,  and  all  unnecessary 
pressure  and  envelopement  are  to  be  deprecated. 

After  the  dressing  has  thus  been  completed,  the  patient,  or 
the  particular  part  involved,  must  be  placed  in  such  a  position 
as  will  most  conduce  to  his  comfort  and  security.  Generally, 
a  dependent  position  is  to  be  avoided ;  to  prevent  it,  pillows 
may  be  placed  beneath  the  limb,  if  the  leg  be  involved,  or,  if 
it  be  the  arm,  a  sling  may  be  used  to  support  it. 

The  surface  may  be  protected, 
FIG.  10.  when  necessary,  from  the  pressure 

of  the  bedclothes,  by  placing  over 
it  an  arch  made  of  two  semi-circles 
of  hoop  crossed  upon  each  other,  or 
of  wires,  or  bamboo,  fixed  in  a 
frame  (fig.  10). 

The  dressing  should  be  disturbed 
as  little  and  as  seldom  as  is  consist- 
ent with  the  successful  treatment  of  the  case;  all  unnecessary 
renewals  should   be  avoided.     Generally,  a  dressing  should 
not  be  renewed,  or  removed,  so  long  as  the  first  remains  in 


GENERAL  RULES  FOR  DRESSING.      51 

place,  is  clean,  free  from  unpleasant  smell,  and  is  comfortably 
borne,  and  so  long  as  no  new  and  untoward  symptom  has 
occurred. 

All  soiled  dressings  of  every  kind,  the  sponges,  basins,  and, 
in  short,  every  thing  which  mars  the  cleanly  appearance  of  the 
sick-room,  or  vitiates  its  atmosphere,  should  be  removed  as 
quickly  as  possible,  and  the  bedding  and  clothing  of  the  pa- 
tient be  kept  clean  and  well  arranged. 


CHAPTER  IV. 

ON    THE     USE    OP    WATEK. 

THE  various  modes  in  which  water  is  made  use  of  as  a  me- 
dicinal agent,  by  the  surgeon  in  his  daily  duties,  constitute  a 
very  important  subject  for  study;  and  one  to  which  a  few 
pages  may  profitably  be  devoted  in  a  treatise  on  Minor  Sur- 
gery. A  brief  consideration,  therefore,  will  be  here  entered 
into  of  Irrigation  ;  the  Douche  ;  the  Water  and  the  Vapour 
Baths,  and  finally  the  subject  of  Fumigations  will  be  noticed. 
The  best  modes  of  insuring  purity  of  the  atmosphere  of  a  sick- 
room, or  of  a  hospital  ward,  will  also  be  briefly  alluded  to. 

SECTION  I. 
IRRIGATION. 

The  surgeon  has  a  very  admirable  substitute  for  the  refri- 
gerant poultice  in  Irrigation,  whereby  the  part  may  be  kept 
constantly  bathed  in  cold  water  of  an  uniform  temperature. 
The  water  may  be  simple,  or  medicated  by  any  of  the  sub- 
stances before  enumerated,  or  others  similar.  The  same  plan 
might  be  used  to  insure  a  hot  or  warm  fomentation,  if  the  fluid 
could  be  maintained  at  one  and  the  same  temperature,  but 
this  would  be  attended  with  so  much  difficulty,  that  it  would 
scarcely  be  prudent  to  attempt  it ;  since  the  alternate  chilling 
and  heating,  to  which  the  part  would  be  exposed,  from  succes- 
sive changes  in  the  therm ometrical  condition  of  the  water, 
would  be  productive  of  serious  inconveniences  and  dangers. 

The  simplest  method  of  effecting  irrigation  is,  to  cover  the 
part  with  folds  of  soft  linen,  or  lint,  previously  moistened,  and 
to  conduct  a  constant  current  of  water  to  it  through  strips  of 
linen,  or  cotton  wick,  from  a  reservoir,  as,  for  example,  a  ba- 
sin placed  at  some  convenient  point.  In  order  that  the  clothes 
of  the  patient,  or  his  bedding,  be  not  wetted,  the  part, — as  a 

(52) 


IRRIGATION. 


53 


limb, — should  be  laid  upon  a  pillow  protected  by  a  piece  of 
oil-cloth  so  arranged  as  to  form  a  sort  of  gutter,  or  funnel, 
along  which  the  water  may  pass  and  fall  into  another  reser- 
voir placed  beneath  it.  M.  Velpeau  employs  an  apparatus, 
to  fulfil  the  same  purpose,  which  possesses  this  advantage,  viz., 
that  by  it  the  amount  of  water  and  the  force  of  the  stream  can 
be  accurately  regulated  at  pleasure,  by  turning  a  stop-cock. 
The  annexed  figure,  (fig.  11,)  taken  from  M.  Velpeau's  work, 

Fia.  11. 


(Med.  Operat.  i.    265,)  sufficiently  explains   the'  apparatus 
which  he  uses. 

The  very  great  benefits  derivable  from  the  free  and  constant 
use  of  cold  water  in  various  surgical  as  well  as  medical  dis- 
5* 


54  THEDOUCHE. 

eases,  have  been  known  for  ages ;  from  time  to  time,  however, 
it  has  been  neglected,  and  again  invoked  :  it  is  now,  once  more, 
resorted  to,  in  the  manner  just  described.  It  is  particularly 
applicable  to  the  early  treatment  of  severe  contused  and  lace- 
rated wounds ;  sprains  ;  simple  contusions  ;  dislocations,  accom- 
panied by  much  pain  after  reduction,  and  many  other  painful 
injuries  and  diseases  of  the  joints  ;  phlegmonous  inflammation  ; 
some  varieties  of  painful  ulcers,  &c.,  &c.  (MM.  Velpeau,  Be- 
rard,  Malgaigne,  South's  Ed.  Chelius,  &c.,  &c.)  The  feelings 
of  the  patient  should  be  consulted,  in  determining  the  propriety 
of  continuing  or  relinquishing  this  plan  of  treatment.  It 
should  be  discontinued,  or  at  least  suspended,  if  it  increase  the 
pain  which  it  was  intended  to  relieve,  or  induce  sensations  of 
chilliness  and  discomfort. 


SECTION  II. 

THE     DOUCHE. 

Another,  and  a  very  beneficial  mode  in  which  water,  either 
warm  or  cold,  may  be  applied  to  the  surface  of  the  body  is, 
by  the  douche,  which  consists  of  a  column  of  water  varying 
in  volume,  made  to  fall  upon  the  body  from  a  greater  or  less 
elevation.  Two  series  of  phenomena  attend  the  action  of 
the  douche:  the  immediate  effect,  or  the  shock,  and  that 
which  follows  it,  or  the  reaction.  The  intensity  of  these 
vary  according  to  the  temperature  of  the  water,  its  volume, 
and  the  height  from  which  it  falls ;  so  that  by  regulating 
these  circumstances,  the  peculiar  effect  to  be  derived  from 
the  douche,  in  each  case,  may  be  obtained.  The  primary,  or 
direct  result  of  the  cold  douche  is  sedative ;  but,  in  ordinary 
cases,  the  nervous  system  more  than  recovers  from  its  tem- 
porary depression,  and  an  excitement  ensues.  This  depres- 
sion may  be  prolonged,  and  the  period  of  excitement  post- 
poned, by  gradually  increasing  the  mass  of  water  which  falls 
upon  the  surface,  or  the  force  with  which  it  descends,  or  the 
height  of  the  column,  or  finally,  by  gradually  lowering  its 
temperature;  and  by  combining  all  these  modifications,  a 
still  greater  effect  will  ensue.  These  circumstances  should 
be  attended  to,  therefore,  where  a  sedative  influence  is  re- 


THE    DOUCHE.  55 

quired.  So  soon  as  a  certain  amount  of  depression  occurs, 
the  action  of  the  douche  may  be  suspended,  and  again  re- 
sumed when  reaction  commences,  as  indicated  by  the  return 
of  the  previous  temperature,  colour,  and  fulness  of  the  part. 
This  alternate  action  and  suspension  of  the  agent  may  be 
continued  so  long  as  may  be  indicated.  After  the  douche, 
the  surface  should  be  gently  dried  by  the  application  of  a 
soft  towel,  so  as  not  to  excite  a  glow.  After  successive  and 
repeated  employment  of  the  remedy,  as  above  recommended, 
it  will  generally  be  found  that  reaction  does  not  occur,  or 
that  it  is  very  moderate  and  within  bounds. 

The  warm  douche  is  productive  of  less  depression,  and  the 
reaction  is  proportionally  less  in  degree,  than  when  the  cold 
is  resorted  to.  Generally,  the  warmer  the  water,  other  cir- 
cumstances being  equal,  the  less  the  effects,  both  primary  and 
secondary. 

To  constitute  the  cold  douche,  the  temperature  of  the  water 
should  be  about  40°  F.,  rarely  lower ;  that  of  the  warm  douche 
may  very  well  be  borne  as  high  as  180°  F.  (Thomson,  op. 
cit.  289.)  The  duration  of  their  employment  must  vary  very 
much ;  in  this  respect  the  condition  of  each  patient  at  the  time 
must  be  the  criterion. 

The  water  used  for  the  douche  is  rarely  medicated,  except- 
ing by  the  addition  of  salt  or  of  sea-water. 

The  douche  is  especially  applicable  to  cases  in  which  it  is 
desirable  to  invigorate  the  vital  functions,  generally,  or  to  in- 
crease the  tone  of  particular  parts  or  organs. 

In  cases  of  considerable  general  debility,  the  system  may 
not  be  able  to  react  sufficiently  if  the  cold  douche  is  employed 
at  first ;  here  it  is  best  to  use  the  warm  water,  and  gradually, 
on  successive  occasions,  to  lower  the  temperature  of  the  douche, 
as  the  individual  may  have  become  stronger.  When  carefully 
employed  in  this  way,  it  is  one  of  the  best  general  tonic  reme- 
dies which  can  be  made  use  of. 

In  local  paralysis  its  good  effects  are  very  manifest ;  as,  for 
instance,  when  directed  upon  the  lower  part  of  the  spine,  in 
cases  of  paralysis,  partial  or  otherwise,  of  the  sphincter  mus- 
cle of  the  anus,  or  neck  of  the  bladder ;  in  a  similar  condition 
of  some  of  the  voluntary  muscles,  as  of  the  deltoid,  resulting 
from  an  injury  to  the  muscle  itself,  the  douche  should  be  di- 
rected upon  the  particular  part.  When  the  loss  of  power  is 


56 


THE    DOUCHE. 


FIG.  12. 


more  general,  the  effect  of  lesion  of  one  of  the  central  organs 
of  the  nervous  system,  it  is  advisable  not  to  employ  this  re- 
medy until  all  the  active  symptoms  of  such  lesion  shall  have 
been  removed :  such  cases  demand  great  watchfulness  on  the 
part  of  the  surgeon. 

The  simplest  mode  of  applying  the  douche  is  to  pour  the 
water  from  the  nose  of  a  teapot,  or  pitcher,  from  some  conve- 
nient height ;  if  a  large  stream  is  desired,  a  basin  or  a  bucket 
can  be  employed.  The  shower-bath  is  a  common  name  for  a 
variety  of  the  douche.  It  is  made  in  numerous  ways.  A  very 
simple  form,  and  one  which  is  very  convenient  for  surgical 
purposes,  particularly  in  young  patients,  "  consists  of  a  hollow 
vessel  made  of  tin,  with  a  perforated  bottom'.  The  body  of 
the  vessel  is  of  a  bell-shape,  with  a  hollow  tube  rising  from  the 
top,  (b)  and  terminating  in  a  broad  perforated  rim.(c)  When 
the  bath  is  to  be  used,  it  must  be  sunk  in  a  bucket  of  water, 
until  it  is  completely  submerged ;  the  air  is  thus  driven  out  of 

the  bath,  which  is  filled  with 
water.  The  thumb  of  an  at- 
tendant is  then  to  be  placed 
upon  the  orifice  in  the  centre 
of  the  rim,  (c)  and  the  bath 
raised  from  the  bucket  of  wa- 
ter. The  pressure  of  the  air 
upon  the  holes  in  the  bottom 
retains  the  water  in  the  bath, 
and  on  raising  the  thumb  from 
the  upper  orifice,  the  water  is 
rapidly  discharged."  (Fig.  12.) 
Portable  shower-baths,  holding 
from  a  quart  to  a  gallon  or 
more  of  water,  are  now  made 
so  that  the  patient  may  hold 
the  vessel  himself  above  his 
head,  and  discharge  the  water  by  raising  a  valve  with  his  fin- 
ger. The  shower  bath  may  act  on  the  whole  surface,  or  upon 
a  single  part  which  is  alone  exposed.  After  its  use,  the  body," 
or  the  parts  which  have  been  wet,  should  be  thoroughly  dried 
by  friction  with  a  towel,  and  the  person  covered  as  soon  as 
possible.  The  best  time  for  making  use  of  the  shower  bath, 


BATHING.  57 

or  the  douche,  if  other  circumstances  will  permit,  is  probably 
soon  after  rising  in  the  morning. 


SECTION  III. 
BATHING. 

Bathing  forms  a  very  important  item  in  the  treatment  of 
many  surgical  diseases,  so  that  a  brief  consideration  of  it  will 
not  be  out  of  place  here. 

Baths  are  of  water,  simple  or  medicated,  and  of  vapour, — 
of  water,  or  of  some  medicinal  substance ;  or,  again,  it  may 
be  a  simple  air-bath ;  the  latter  is  not  much  resorted  to  as  a 
remedial  agent. 

The  water-baths  are  of  most  frequent  use.  For  conve- 
nience-sake, they  may  be  classed  as  the  cold  (temp.  33°  to 
60°  F.) ;  the  cool  (60°  to  75°) ;  the  temperate  (75°  to  85°) ; 
the  warm  (92°  to  98°);  and  the  hot  (98°  to  112°).  (Forbes, 
art.  "Bathing,"  in  Cyclop.  Pract.  Med.)  The  thermometer, 
though  answering  very  well  as  a  general  index  of  the  tem- 
perature of  the  bath,  is  really  a  very  arbitrary  guide  in  pre- 
paring baths  for  particular  individuals;  since  a  degree  of 
temperature  which  one  person  may  consider  "warm,"  or 
u  temperate,"  may  to  another  be  disagreeably  cold ;  the  feel- 
ings of  the  patient,  guided  by  the  judgment  of  the  attendant, 
constitute  a  much  more  rational  and  a  safer  guide. 

As  in  the  case  of  the  douche,  two  series  of  effects  are  ma- 
nifest when  one  takes, a  bath:  the  primary  and  the  secondary. 
These  vary  in  degree,  with  the  temperature  of  the  water. 
The  greater  the  difference  between  the  temperature  of  the 
bath  and  that  of  the  body,  the  more  marked  will  be  the  im- 
mediate effects,  or  the  shock ;  and  these  will  be  depressing,  or 
stimulating,  as  the  temperature  of  the  water  is  below  or 
above  that  of  the  surface,  and  proportionally  so.  A  cool, 
and  still  more  a  cold,  bath  produces  directly  a  sedative  or 
depressing  effect ;  but  in  the  course  of  a  few  minutes,  unless 
the  patient  be  very  feeble  indeed,  the  system  recovers  from 
this,  and  an  excitement,  proportioned  to  the  previous  de- 
pression, takes  its  place.  This  condition  continues  a  longer 
or  shorter  time,  and  a  second  stage  of  depression  ensues, 


58  BATHING. 

from  which  reaction  does  not  occur,  so  long  as  the  individual 
is  exposed  to  the  same  temperature.  After  the  patient  is 
removed  from  the  bath  and  properly  attended  to,  the  excite- 
ment continues  for  a  time,  and  then  gradually  the  system  re- 
acquires  its  former  standard,  or  retains  permanently  a  mode- 
rate elevation. 

A  hot  bath  produces  immediately  an  excitement  of  the 
system,  as  indicated  by  fulness  of  the  superficial  vessels, 
flushing  of  the  face,  increased  force  and  frequency  of  the 
heart's  action^  throbbing  of  the  vessels  of  the  head  and  neck  ; 
the  latter  phenomena  are  sometimes  so  strongly  manifest  as 
to  require  the  employment  of  cold  applications  to  the  head, 
and  even  the  use  of  the  lancet.  Soon,  however,  either  with 
or  without  the  aids  just  mentioned,  perspiration  breaks  out 
very  freely  upon  the  face,  the  excitement  of  the  heart  sub- 
sides, and  the  patient  becomes  more  and  more  relaxed,  and 
not  unfrequently  faints ;  this  condition  of  relaxation  continues 
for  a  considerable  time  after  the  bathing  has  ceased. 

The  warm  bath  generally  produces  a  soothing,  tranquil- 
lizing influence,  allays  restlessness,  assuages  pain,  and  often 
induces  delightful  sleep.  The  excitement  which  it  causes  is 
very  moderate,  and  if  used  permanently,  it  may  be  considered 
an  excellent  tonic,  as  is  the  cool  or  cold  bath,  under  proper 
regulations.  • 

Bathing  is,  therefore,  applicable  to  a  variety  of  surgical 
diseases.  As  a  calmative  agent,  it  is  employed  in  numerous 
subacute  inflammations,  in  many  diseases  of  the  skin,  &c.,  &c. 
As  a  tonic,  it  is  applicable  to  cases  of  general  or  local  debility ; 
as  a  stimulant,  to  the  same  sorts  of  complaints ;  as  a  depress- 
ing remedy,  it  is  often  made  use  of  to  overcome  violent  pain, 
spasmodic  muscular  contraction,  as  in  the  reduction  of  dislo- 
cations, to  allay  spasm  of  the  neck  of  the  bladder,  to  aid  in 
the  return  of  a  hernial  protrusion,  and  the  like. 

In  giving  a  bath,  the  water  should  be  preserved,  as  far  as 
possible,  at  the  same  temperature  throughout  its  use.  When 
the  bathing  is  completed,  the  individual  should  be  carefully 
rubbed  dry  with  towels,  and  protected  from  exposure  to  a 
current  of  air. 

Common  sense  will  suggest  at  the  time  some  apparatus 
suitable  for  the  administration  of  this  remedy;  if  possible, 
it  should  be  large  enough  to  contain  the  entire  person,  but  in 


BATHING. 


59 


the  absence  of  such  a  convenience,  a  common  water-cask 
might  be  employed,  or  a  washing-tub ;— care  being  observed, 
if  the  bath  be  warm,  to  protect,  by  a  blanket,  such  portion 


FIG.  13. 


of  the  surface  as  may  be  uncovered  by  the  water.  Dr. 
Thomson  (op.  cit.,  p.  296)  has  cotitrived  a  very  convenient 
apparatus  for  bathing  ;  he  thus  describes  it : — "  It  consists 
of  a  hammock  (a)  of  Macintosh's  cloth,  which  is  extended 
upon  two  long  poles  (b  b\  passed  through  a  broad  seam  on 
each  side  of  the  hammock,  and  kept  asunder  by  the  cross 
pieces  (c  <?),  which  are  attached  to  the  poles  by  the  thumb- 
screws (ddd).  At  one  end  of  the  hammock  is  an  air-pillow, 
which  can  be  readily  blown  up ;  and  below  it,  is  a  flexible 
tube  (/),  made  of  the  same  material  as  the  hammock,  by 
which  any  water  it  may  contain  can  be  readily  drawn  off. 
When  the  poles  are  fixed,  as  in  the  above  figure,  and  the 
open  end  of  the  flexible  tube  is  twisted  around  one  of  the 
thumb-screws,  the  bath  is  ready  to  receive  the  water.  It  may 
be  supported  upon  two  chairs,  or  upon  folding  tressels  (e  e). 
The  advantage  of  this  bath  is,  that  it  requires  a  very  small 
quantity  of  water  compared  to  that  demanded  for  other 
baths ;  that  it  requires  no  sheet  for  the  bather  to  rest  upon ; 
and,  when  the  bathing  is  completed,  the  poles  and  the  folding 
tressels  can  be  placed  aside  in  a  small  closet,  or  in  the  corner 
of  a  dressing-room,  and  the  hammock,  when  dried,  put  into  a 
drawer."  This  apparatus  will  be  found  very  convenient  on 
board  ship,  or  in  camp,  where  convenience  in  transportation 
and  economy  of  space  must  be  consulted.  (Fig.  13.) 

Partial  ba.ths  are  very  often  used,  and  are  of  great  service 
in  many  cases.  Thus  the  pediluviurn,  or  foot-bath,  may  be 
the  means  of  effecting  powerful  and  efficient  derivation  from 


60  B  A  T  H  I N  G  j 

the  head,  and  of  inducing  a  considerable  degree  of  relaxation 
of  the  whole  frame.  An  ordinary  bucket  may  be  partially 
filled  with  water  of  as  high  a  temperature  as  the  patient  can 
bear,  rendered  more  powerful,  if  desired,  by  the  addition  of 
mustard-flour  or  cayenne  pepper,  or  some  liquid  stimulant ; 
the  patient  may  sit  up  in  a  chair,  while  the  feet  are  in  the 
water,  or  he  may  remain  in  bed,  with  his  limbs  projecting 
over  its  edge  into  the  bucket  which  is  supported  upon  a  chair 
conveniently  placed.  He  should  be  well  wrapped  up  during 
the  process ;  from  time  to  time,  portions  of  water  should  be 
withdrawn  from  the  bucket,  and  hot  water  added.  The  bath 
may  be  continued  for  fifteen  or  twenty  minutes,  or  longer. 

The  hip-bath  furnishes  a  very  conve- 
14.  nient  and  powerful  means  of  acting  upon 

the  lower  part  of  the  spinal  marrow  and 
((  ^^^^  tne  Pelyic  organs.  It  may  be  very  well 
taken  in  a  vessel,  of  which  the  annexed 
drawing  illustrates  the  form ;  it  has  the 
important  advantage  of  well  supporting 
the  back,  while  the  patient  is  in  the  sit- 
ting posture.  (Fig.  14.) 

Baths  are  variously  medicated  to  suit 
particular  indications ;    several    of  such 
modifications  will  be  given  at  the  end  of  the  volume. 

The  VAPOUR  BATH  may  be  made  to  answer  many  of  the  in- 
dications fulfilled  by  the  water  bath ;  its  general  effects  are 
very  similar.  The  intensity  of  its  action  varies  much,  accord- 
ing as  it  is  allowed  to  act  upon  the  surface  merely,  or  as  it  is 
inhaled  also.  Dr.  Forbes,  (art.  "Bathing,"  op.  cit.)  gives  the 
following  comparative  statement,  by  which  it  is  supposed  that 
the  vapour  bath  produces  effects  equal  to 

The  tepid  bath,  at  85°—  92°,  its  own  temp,  being  90°— 106°,    90°— 100° 
"    warm     "          92°—  98°,     "  "  106°— 120°,  100°— 110° 

«    hot         "         98°— 106°,     "  «  120°— 160°,  110°— 130° 

Not  breathed.     Breathed. 

Their  administration  is  very  simple,  and  is  attended  with 
less  inconvenience,  oftentimes,  than  the  use  of  the  water  bath. 
The  readiest  mode  of  giving  a  vapour  bath  is  to  seat  the  pa- 
tient upon  a  chair,  and  at  his  feet  place  the  vessel  of  water 
sufficiently  heated  j  surround  the  whole, — patient,  chair,  and 


FUMIGATIONS.  61 

,ter, — wVh  a  blanket,  or  a  mantle  of  waxed  or  oiled  cloth, 
or  of  Indian  'ubber  cloth,  which  may  envelope  the  head,  if  it  be 
considered  a  tlvisable  that  the  vapour  be  inhaled,  or  simply  en- 
closing the i  ieck,  if  otherwise;  to  keep  the  water  at  a  proper 
temperatup/,  a  heated  brick  may  be  immersed  in  it,  or  the 
v  x^sel  pl^Oed  upon  it,  from  time  to  time,  as  required  by  the 
lowering  temperature  of  the  fluid.  If  the  patient  remain  in 
bed,  a  flexible  tube  can  be  easily  introduced  beneath  the  bed- 
clothes, communicating  with  the  interior  of  a  vessel,  as  an  or- 
dinary tea-kettle,  in  which  vapour  is  being  generated :  or  a 
plate  containing  the  fluid  and  a  hot  brick  may  be  placed  in 
the  bed,  and  an  arched  framework  thrown  over  it  to  protect 
the  bedclothes. 


SECTION   IV. 
ON    FUMIGATIONS. 

When  solid  substances  are  vaporized,  and  thus  made  to  act 
upon  the  surface,  as  medicinal  agents,  the  process  is  called 
Fumigation,  and  is  effected  by  placing  the  substance  to  be 
used  in  contact  with  a  body  heated  at  a  sufficient  temperature, 
and  so  arranging  the  position  of  the  patient  as  that  the  fumes 
may  come  in  contact  with  his  surface.  The  arrangements 
recommended  above  in  the  application  of  the  vapour  bath  may 
be  employed  likewise  in  fumigating  ;  the  same,  or  even  greater, 
care  being  observed  to  protect  the  air-passages,  if  the  fumes 
are  irritating,  or  not  intended  to  be  inhaled :  again,  a  large 
box,  or  a  hogshead,  may  answer  very  well,  being  so  contrived 
as  that  the  head  may  be  guarded  against  the  vapour. 

The  articles  most  frequently  employed  in  fumigating  the 
surface,  or  a  particular  part  of  it, — are  sulphur,  nitre,  cinna- 
bar, arsenic,  benzoic  acid,  chlorine  gas,  nitrous  acid,  &c.,  &c. 

Vapours,  whether  by  the  vapour  bath,  or  by  fumigation,  are 
chiefly  employed  in  affections  of  the  skin,  some  forms  of  chro- 
nic rheumatism,  periostitis,  and  the  like. 
6 


62  DISINFECTING    AGE  NTS. 

SECTION   V. 
ON    DISINFECTING    AGENTS. 

A  pure  atmosphere  is  one  of  the  most  important  requisites 
in  the  treatment  of  disease,  and  it  is  one  which,  in  surgical 
practice  particularly,  is  difficult  of  acquisition  oftentimes.  It 
becomes  necessary,  therefore,  that  the  surgeon  should  devote 
some  attention  to  this  matter. 

The  method  which  suggests  itself  most  naturally  to  the 
attendant  is,  to  effect  as  perfect  ventilation  as  circumstances 
will  permit.  For  this  purpose,  some  method  should  be 
adopted  whereby  the  air  in  the  patient's  apartment  shall  be 
frequently  renewed  by  the  introduction  of  fresh  air  from 
without,  displacing  that  within  the  room.  When  the  tempe- 
rature is  such  as  to  admit  of  keeping  a  fire  in  the  chamber, 
the  vitiated  atmosphere  will  ascend  freely  through  the 
chimney,  thus  allowing  pure  air  to  take  its  place;  but  in 
warm  weather  this  source  of  purification  is  cut  off,  and  the 
surgeon  is  obliged  to  rely  chiefly  upon  the  windows  and  doors, 
as  affording  avenues  through  which  an  interchange  may  be 
effected  of  the  air  within  and  without.  This  mode  of  purifi- 
cation may  be  much  aided  by  the  use  of  various  disinfecting 
agents,  which  neutralize,  more  or  less,  the  exhalations  and 
effluvia  within  the  sick-room.  Of  these,  the  various  sub- 
stances which  contain  chlorine  are  most  in  use.  They  pro- 
bably produce  their  effect  by  the  liberation  of  chlorine  gas, 
which  combines  with  the  offending  gases.  The  chlorides  of 
calcium  and  of  sodium  are  the  compounds  generally  employed 
as  disinfectants ;  they  are  used  in  a  solid  state,  placed  in 
different  parts  of  the  room,  in  some  suitable  dish,  and  kept 
moistened  with  water,  or  with  dilute  sulphuric  acid,  which  is 
still  better ;  or  they  may  be  rendered  liquid  for  application  to 
the  surface  of  the  body  and  to  the  bedclothes  of  the  patient. 
The  liquid  chloride  of  calcium  may  ^be  prepared  thus : — 
Introduce  into  a  common  glass  retort  fourteen  parts  of  black 
oxide  of  manganese,  six  parts  of  chloride  of  sodium,  the  same 
proportion  of  sulphuric  acid,  and  twelve  parts  of  water.  The 
chlorine  gas  will  be  evolved  without  the  aid  of  heat  applied, 


DISINFECTING    AGENTS. 


63 


and  should  be  transmitted  through  a  tube  attached  to  the 
neck  of  the  retort  to  the  bottom  of  a  vessel  filled  with  a  satu- 
rated solution  of  lime,  until  the  evolution  ceases.  The  water 
thus  impregnated  should  be  diluted  with  about  forty  parts  of 
fresh  water,  for  ordinary  use. 

The  liquid  chloride  of  sodium  is  prepared  in  the  same 
manner:  a  solution  of  one  part  of  sub-carbonate  of  soda,  in 
twenty  parts  of  water,  being  substituted  for  the  lime-water. 
The  solution  should  be  diluted  with  about  thirty  parts  of 
water.  These  liquids  are  sprinkled  upon  the  patient's  clothes 
and  bedding,  and  a  portion  may  be  added  to  the  water  used 
in  washing  any  diseased  part :  for  this  latter  purpose,  the  so- 
lution of  the  chloride  of  sodium  is  generally  preferred,  (Cyclop. 
Pract.  Med.) 

Labarraque's  solutions  of  these  chlorides  are  now  sold  very 
generally  throughout  the  country. 

A  solution  of  the  chloride  of  zinc  is  also  employed  as  a  cor- 
recter  of  the  atmosphere. 

Chlorine  gas  may  be  very  easily  liberated  from  common 
salt,  by  pouring  concentrated  sulphuric  acid  upon  it,  in  the 
proportion  of  one  part  of  the  acid  to  three  parts  of  the 
salt. 

An  objection  to  the  use  of  the  chlorides  arises  from  the 
smell  of  the  preparations  themselves  being  disagreeable  to 
many  persons. 

Fumigations  by  nitrous  acid  vapour  have  been  resorted  to, 
and  with  much  success.  The  vapour  is  obtained  by  the  action 
of  sulphuric  acid  on  nitrate  of  potassa,  in  equal  proportions, 
without  the  aid  of  heat ;  care  is  necessary  lest  the  fumes  be 
disengaged  too  rapidly  and  too  abundantly,  and  thus  prove  a 
source  of  irritation  to  the  respiratory  muscles. 

The  common  quicklime  possesses  the  power  of  absorbing 
many  of  the  gases  on  which  the  noisome  atmosphere  of  the 
sick  room  depends.  It  is  placed  in  plates,  or  other  dishes, 
and  set  in  various  parts  of  the  chamber. 

M.  Le  Doyen  has  recently  recommended  a  disinfecting 
agent  which  seems  to  possess  many  advantages  over  the 
others,  and  a  very  important  excellence  of  this  preparation 
is,  that  it  has  no  odour  itself.  It  consists  of  a  solution  of 
the  nitrate  of  lead,  and  can  be  prepared  by  dissolving  litharge 


64  DISINFECTING    AGENTS. 

in  one  part  of  nitric  acid,  mixed  with  about  ten  parts  \  $ 
water.  It  is  used  in  the  same  way  as  the  liquid  chlorides. 

To  insure  any  degree  of  purity  of  atmosphere,  it  is  abso- 
lutely essential  that  the  patient's  apartment  be  kept  clean, 
and  that  all  useless  clothing  and  furniture,  which  may  attract 
offending  gases,  be  removed.  The  dressings  which  have  been 
changed,  the  water  with  which  diseased  parts  have  been 
cleansed,  all  vessels  containing  discharges  from  the  patient, 
should  be  taken  out  of  the  room  as  soon  as  possible.  Fre- 
quent white-washing  of  the  walls  and  ceiling  of  the  chamber 
will  conduce  very  much  to  the  preservation  of  a  pure  atmo- 
sphere, probably  on  account  of  the  absorbing  property  of  the 
lime  over  the  effluvia. 

The  most  efficacious  method  for  disinfecting  substances, 
such  as  clothing,  which  retain  infectious  agents,  is  to  expose 
them  to  an  elevated  temperature,  as,  for  example,  a  tempera- 
ture of  200°  or  more,  of  Fahrenheit's  scale;  the  heat  may 
be  employed  dry,  or  in  the  form  of  steam.  The  action  of 
heat  is  effectual  in  a  very  much  shorter  time  than  an  ordinary 
current  of  air. 


PAKT   II. 

ON  BANDAGES  AND  THEIR  APPLICATION. 
CHAPTER  I. 

BANDAGES  are  employed  in  surgery  to  retain  dressings 
upon  the  surface  of  the  body,  or  other  applications ;  and  also 
as  a  means  of  restoring  and  confining  to  their  natural  situa- 
tion parts  which  may  have  become  displaced. 

The  materials  used  for  bandages  are  generally  muslin, 
linen,  flannel,  or  calico :  sometimes  gum-elastic  cloth  may  be 
employed.  Of  these  materials  that  which  is  most  frequently 
selected  is  muslin,  either  bleached  or  unbleached ;  it  is  cheap, 
and  everywhere  to  be  found.  Flannel  is,  in  some  circum- 
stances, preferable  to  muslin,  in  consequence  of  its  greater 
warmth  and  elasticity. 

Bandages  are  simple,  as  when  formed  from  the  roller ;  or 
compound,  when  prepared  from  one  or  more  pieces  adapted 
by  size  and  conformation  to  particular  objects. 

We  shall  first  describe  the  different  bandages  commonly 
employed,  arid  then  treat  of  their  several  uses,  as  applicable 
to  the  different  regions  of  the  body. 

SECTION  I. 
THE   ROLLER,    OR   SIMPLE   BANDAGE. 

There  are  but  very  few  of  the  ends  ordinarily  to  be  attained 
by  bandaging,  which  may  not  be  gained  by  a  skilful  dresser 
with  the  simple  roller. 

It  is  prepared  from  any  of  the  materials  above-mentioned, 
but  for  general  purposes  muslin  is  selected.  It  should  be 
torn  or  cut  into  strips,  varying  in  length  and  width,  accord- 
ing to  the  part  to  which  it  is  to  be  applied,  and  rolled  into 
6*  (65) 


66 


THE    ROLLER,    OR    SIMPLE    BANDAGE. 


the  form  of  a  solid  cylinder:  this  latter  object  maybe  effected 
by  the  hands  alone,  or  by  making  use  of  a  very  simple  ma- 
chine contrived  for  the  purpose.  If  rolled  by  the  hands,  the 
strip  should  be  folded  at  one  extremity  several  times,  until  it 
shall  have  acquired  a  certain  degree  of  solidity;  then  the 
ends  of  this  axis  are  held,  and  its  mass  made  to  revolve,  be- 
tween the  thumb  and  forefinger  of  the  right  hand,  while  the 
free  portion  of  the  strip  is  pressed  by  the  thumb  and  fore- 
finger of  the  left  hand,  and  allowed  to  pass  from  between  them, 
smoothly,  and  with  some  degree  of  tension,  as  the  cylinder  is 
gradually  forming. 

Figure  15  presents  a  view  of  a  machine  for  rolling  the 
simple  bandage  :  it  sufficiently  explains  itself. 

FIG.  15. 


If  but  a  single  cylinder  is  formed,  the  roller  is  said  to  be 
"  single-headed  ;"  if  there  be  a  cylinder  rolled  at  each  extre- 
mity of  the  strip,  it  is  called  "double-headed,"  and  the  un- 
rolled portion  between  the  two  cylinders  is  termed  the  "  body" 
of  the  roller. 

In  applying  this  bandage,  the  external  Surface  of  the  free 
extremity  of  the  roller  is  laid  upon  the  part,  and  retained 
there  by  the  fingers  of  the  left  hand,  until  fixed  by  a  few 
turns  of  the  roller,  the  cylinder  being  held  in  the  palm  of  the 
right  hand  by  the  thumb  and  fingers ;  care  is  necessary  that 
the  bandage  be  laid  smoothly  and  evenly  upon  the  surface, 
and  that  a  uniform  degree  of  pressure  be  exerted  by  each 
successive  turn.  After  the  rolling  is  completed,  the  free 


THE    ROLLER,    OR    SIMPLE    BANDAGE.          67 

extremity  of  the  bandage  is  most  easily  confined  by  a  pin 
inserted  transversely,  or  if  parallel  with  the  length  of  the 
bandage,  the  pin  should  be  introduced  with  its  point  towards 
the  free  end  of  the  roller,  otherwise  it  is  liable  to  be  drawn 
out  by  the  constant  strain  of  the  bandage  upon  it.  When 
the  part  to  which  the  bandage  has  been  applied  is  very  small 
in  circumference,  and  the  bandage  itself  very  narrow,  the 
extremity  of  the  latter  may  be  conveniently  attached  by  slit- 
ting it  longitudinally  through  the  middle,  and  tying  the  ends 
around  the  part ;  as,  for  example,  the  finger  or  toe. 

Sometimes  the  roller  may  be  wetted  previous  to  its  appli- 
cation, as,  for  instance,  when  it  is  used  to  confine  the  band 
to  which  the  pulleys  are  attached,  in  the  process  for  reducing 
a  dislocation ;  the  band  is  thus  more  firmly  secured  than  when 
a  dry  roller  is  employed.  But  in  ordinary  cases  of  bandaging, 
a  wet  roller  should  not  be  used,  for  as  it  dries,  it  shrinks  and 
produces  a  much  greater  degree  of  pressure  upon  the  soft 
parts  than  is  consistent  with  safety. 

In  some  cases  it  may  be  advisable  to  saturate  the  bandage 
with  starch,  which,  when  it  has  become  dry,  forms  a  stiff, 
firm  casement.  A  'more  particular  mention  of  this,  consti- 
tuting what  is  generally  called  "the  immovable  dressing," 
will  be  made  hereafter. 

The  simple  bandage  receives  different  appellations  ac- 
cording to  the  mode  of  its  application,  or  the  direction  which 
the  roller  is  made  to  assume ;  and  again,  with  reference  to 
the  object  to  be  accomplished  by  it.  Under  the  first  division 
we  have  the  circular,  the  spiral,  the  crossed,  the  spica,  and 
the  recurrent  bandages.  The  second  division  embraces  the 
uniting,  the  dividing,  the  compressing,  the  expelling,  and  the 
retaining  bandages. 

1.  The  CIRCULAR  is  that  of  which  the  folds  are  horizontally 
disposed,  or  nearly  so ;  each  successive  fold  almost  completely 
overlapping  that  which  preceded  it.     (Fig.  16,  a.) 

2.  The  SPIRAL  ascends  obliquely  around  parts  more  or  less 
conical   in   form,   each   fold   of   the   roller   applying    itself 
smoothly  and  flatly  to  the  surface.     Sometimes  the  edges  of 
the  roller  overlap  each  other  at  each  successive  turn,  when 
the  bandage  is  termed  by  the  French,  "  en  doloires ;  some- 
times a  space  intervenes  between  the  folds,  in  which  case  it  is 
termed  " rampant:"  fig.  16,  c  and  b.     If  a  limb,  or  any 


68 


THE  ROLLER,  OR  SIMPLE  BANDAGE. 


FIG.  16. 


r  part  of  irregular  form,  is  to  be  bandaged  .in  its  length, 
it  will  be  impossible  to  cover  its  surface  wholly,  and  at  the 

same  time  to  make  equable 
pressure  upon  it  at  all  points, 
by  simple  spiral  turns:  one 
of  the  edges  of  the  roller 
will  compress  the  surface 
more  or  less  tightly,  while  the 
other  will  be  loose.  In  order 
to  obviate  this  difficulty  it  is 
necessary  to  reverse  the  turns 
of  the  roller,  from  time  to 
time,  as  the  varying  form  of 
the  part  may  require :  fig.  16, 
d.  Some  considerable  prac- 
tice is  needful  to  enable  the 
dresser  to  make  these  reverse 
turns  rapidly  and  neatly. 
The  object  is  to  reverse  the 
relative  positions  of  the  edges 
and  surfaces  of  the  bandage, 
whereby  its  superior  edge 
shall  become  the  inferior,  and 
the  external  face  the  internal. 

To  accomplish  this  end  properly,  the  spiral  should  be  discon- 
tinued so  soon  as  the  bandage  ceases  to  apply  itself  smoothly 
and  flatly  to  the  surface ;  at  this  point  two  or  more  fingers 
of  the  left  hand  should  be  laid  upon  the  roller  at  its  superior 
edge,  and  the  right  hand,  in  which  the  cylinder  is  held  as 
before  directed,  and  which,  until  now,  has  been  kept  supine, 
should  be  pronated,  while  the  body  of  the  roller,  thus  re- 
versed, is  suffered  to  apply  itself,  without  traction,  partly 
upon  the  preceding  fold,  and  partly  upon  the  surface  which 
is  to  be  covered ;  then  the  cylinder  is  carried  around  to  the 
opposite  side  of  the  limb,  and  the  process  just  described  re- 
peated. "  The  hand  should  press  tightly  upon  each  reverse 
to  flatten  and  equalize  it.  (Fig.  17.) 

"  Two  precautions  are  to  be  observed  in  applying  the  re 
versed  bandage ;  one  is,  not  to  unroll,  in  making  the  angle, 
more  of  the  band  than  is  absolutely  necessary;  the  other,  to 
carry  the  angles  upwards  in  a  perpendicular  line,  and  always 


THE    ROLLER,  OR    SIMPLE    BANDAGE. 


69 


far  from  the  part  affected,"  in  order  that  the  increased  thick- 
ness of  the  bandage  at  the  angle  or  fold,  shall  not  produce  a 
corresponding  pressure  and  indentation  upon  the  diseased  or 
injured  surface.  (Cutler,  p.  25.)  Each  successive  turn  of 


FIG.  17. 


the  roller  should  overlap  from  one-third  to  one-half  of  that 
which  preceded  it,  the  edges  being  made,  as  far  as  possible, 
parallel  with  each  other. 

3.  The  CROSSED  bandage  is  made  by  giving  the  turns  of 
the  roller  the  form  of  the  figure  8,  as  is  exemplified  in  the  an- 
nexed drawing  (fig.  18),  in  which  the  bandage  is  supposed  to 
be  applied  to  the  bend  of  the  arm  after  the  operation  of  phle- 
botomy, to  compress  the  incised  vein. 

4.  "  When  the  turns  of  the  roller  cross  each  other  in  the 
form  of  the  Greek  lambda,  and  leave  the  band  about  one-third 
discovered,  the  A'S  being  applied  upon  each  other,  the  bandage 


70     THE  ROLLER,  OR  SIMPLE  BANDAGE. 

receives  the  name  of  spica  ;  fig.  16  e :  it  is  said  to  be  ascend- 
ant when  the  doloires  are  directed 
towards  the  superior  part  of  the 
member,  and  descendant  when  they 
regard  inferiorly."  (Cutler,  p.  25.) 
5.  The  RECURRENT  bandage  is 
applied  to  the  head  more  frequently 
perhaps  than  to  any  other  part. 
It  derives  its  name  from  the  fact 
that  the  roller,  after  covering  a 
certain  portion  of  the  surface,  is 
reflected  in  its  course  and  brought 
back  to  its  original  point  of  depar- 
ture, at  which  it  is  again  reversed 
towards  the  opposite  point;.  This 
process  is  continued  until  the  en- 
tire surface  is  covered ;  each  successive  fold  overlaying  one- 
third,  or  more,  of  that  which  preceded  it,  and  being  confined 
at  its  point  of  reflection,  temporarily  by  the  fingers,  and  per- 
manently by  pins  or  by  a  circular  turn  of  the  roller,  when  the 
bandaging  is  completed.  It  forms  an  exceedingly  neat  and 
beautiful  dressing. 

The  same  bandage  is  employed  as  an  envelope  to  stumps, 
after  amputation,  for  the  purpose  of  retaining  the  other  appli- 
cations which  have  been  made. 

1.  The  UNITING  bandage,  as  it  has  its  almost  exclusive  ap- 
plication to  the  treatment  of  wounds,  will  be  considered  when 
that  class  of  affections  is  treated  of. 

2.  The  DIVIDING  bandage  is  employed  in  the  treatment  of 
burns  and  granulating  surfaces,  where  there  has  been  much 
loss  of  substance,  and  where  unsightly  cicatrices  are  liable  to 
be  formed,  and  deformities  from  the  approximation  of  opposed 
surfaces.     The  object  of  this  bandage  is,  to  obviate  such  ap- 
prehended difficulties  by  maintaining  a  proper  separation  of 
the  parts :  thus,  for  example,  when  the  anterior  face  of  the 
neck  has  been  deeply  injured  by  a  burn,  the  lower  jaw  and  the 
head  should  be  prevented  from  being  drawn  towards  the  chest, 
as  the  ulcer  cicatrizes,  by  means  of  a  dividing  bandage,  hav- 
ing its  point  d'appui  around  the  shoulders  and  in  the  axillae. 
It  is  generally  formed  of  the  simple  roller. 

3.  The  COMPRESSING  bandage,  as  may  be  inferred  from  its 


THE  ROLLER,  OR  SIMPLE  BANDAGE.     71 

name,  is  employed  to  exercise  pressure  upon  a  superficial,  or 
a  deep-seated,  part.  Sometimes  the  roller  is  used  alone,  some- 
times its  action  is  assisted  by  a  compress. 

4.  The  EXPELLING  bandage,  like  the  one  last  mentioned, 
consists  of  a  roller,  generally  applied  over  a  compress.     It  is 
employed  to  facilitate  the  expulsion  of  fluids  from  morbid  ca- 
vities and  canals. 

5.  The  RETAINING  bandage  is  used  to  confine  dressings  in 
place,  as  also  parts  of  the  body  which,  having  become  re- 
moved from  their  natural  positions,  are  replaced. 

6.  The  KNOTTED  bandage  is  sometimes  advantageously  em- 
ployed to  arrest  bleeding,  particularly  of  the  temporal  artery ; 
it  will  be  described  hereafter. 

The  ability  skilfully  and  neatly  to  apply  and  adjust  the 
roller,  is  of  very  great  importance  to  the  surgeon ;  and  the 
time  which  the  young  dresser  devotes  to  its  acquisition  is  well 
spent.  It  can  only  be  gained  by  frequent  practice;  verbal 
descriptions,  and  the  best  executed  illustrations,  should  be  con- 
sidered merely  as  guides  and  aids ;  they  cannot  impart  prac- 
tical skill,  any  more  than  the  perusal  of  volumes  on  anatomy, 
to  the  exclusion  of  dissections,  can  render  the  student  ac- 
quainted with  the  mysterious  construction  of  his  material 
frame.  Let  each  one,  therefore,  spend  a  few  leisure  moments 
every  day,  with  some  companion,  in  the  practical  application 
of  the  roller :  at  first,  reference  to  some  book  on  bandaging 
will  be  necessary,  but  after  a  certain  degree  of  skill  has  been 
acquired,  the  volume  may  be  laid  aside ;  the  student's  good 
sense,  and  the  familiarity  which  he  has  already  gained  with 
the  mode  of  bandaging,  combined  with  his  knowledge  of  the 
particular  object  to  be  attained  in  each  case,  will  be  his  best 
guides  and  his  best  adviser.  The  more  skilful  he  becomes  in 
the  management  of  the  roller,  the  more  entirely  will  he  be 
able  to  dispense  with  compound  and  complicated  bandages ; 
the  more  capable  will  he  be  to  accomplish  all  that  he  desires 
by  this  simple  means. 


72  COMPOUND  BANDAGES. 

SECTION  II. 
COMPOUND  BANDAGES. 

These  are  intended  to  fulfil  some  especial  indication,  which 
owing,  it  may  be,  to  the  peculiar  conformation  of  the  part  o" 
parts  involved,  cannot  be  so  well  attained  by  the  simple  roll 
They  are  formed  of  one  piece,  or  many  pieces,  of  muslin  *• 
of  some  other  material,  to  which  are  given  a  shape  anc7  Con- 
formation varying  according  to  the  judgment  of  the  (L-esser. 
There  are  some  bandages,  however,  so  commonly  made  use  of, 
that  they  require  particular  description.  Such  are  the  cru- 
cial, or,  as  it  is  generally  called,  the  T  bandage ;  the  invagi- 
nated ;  the  many-tailed,  or  the  split ;  the  laced ;  the  sheath, 
and  the  suspensory  bandages. 

1.  The  T  bandage  derives  its  name  from  its  shape.     It  con- 
sists of  a  horizontal  band  to  which  is  attached  another  at  about 
its  middle,  having  a  vertical  direction,  perpendicular  to  the 
first ;  when  there  are  two  vertical  bands,  it  forms  the  double 
T  bandage.     The  length  and  breadth  of  the  strips  vary  with 
the  dimensions  of  the  part  of  the  body  to  which  the  bandage 
is  to  be  applied,  and  the  particular  end  which  it  is  expected 
to  secure.     Sometimes,  as  for  example,  when  it  is  employed 
to  retain  dressings  upon  the  hand,  one  of  the  bands  is  perfo- 
rated to  admit  of  the  insertion  of  the  fingers. 

2.  The  INVAGINATED  bandage  is  used  to  approximate  the 
edges  of  wounds,  or  fragments  of  bone,  as  in  fracture  of  the 
patella.     It  is  made  in  two  different  ways,  according  to  the 
indication  to  be  fulfilled  by  it.     Thus,  if  the  object  be  to  draw 
together  the  lips  of  a  longitudinal  wound  of  a  limb,  a  roller 
should  be  selected  corresponding  in  width  to  the  length  of  the 
wound,  and  long  enough  to  be  passed  several  times  around  the 
limb.     At  its  free  extremity  it  should  be  slit  into  two  or  more 
tails  of  a  convenient  length,  and  corresponding  fenestrse  be 
made  in  the  band  at  a  distance  from  the  end  rather  greater 
than  the  circumference  of  the  limb.     In  its  application,  the 
undivided  portion  of  the  band  should  be  placed  opposite  to  the 
wound,  and  the  tails  passed  through  the  fenestrae,  thus  sur- 
rounding the  limb  ;  then,  with  a  compress  placed  near  each  lip 


COMPOUND    BANDAGES.  73 

of  the  wound,  its  edges  should  be  gently  but  accurately  ap- 
proximated, and  retained  in  apposition  by  several  turns  of  the 
roller.  For  an  illustration  of  this,  see  the  Chapter  on 
Wounds. 

The  invaginated  bandage  for  transverse  wounds,  fracture 
of  the  patella,  &c,  is  made  upon  the  same  principle  precisely; 
it  consists  of  two  bands  of  convenient  length  and  width,  and 
of  two  rollers.  Slits,  as  in  the  other  bandage,  are  made  at 
one  end  of  one  of  the  bands,  and  corresponding  fenestrae  near 
one  extremity  of  the  other ;  then,  by  means  of  the  rollers, 
firmly  attach  the  bands  to  the  limb,  the  one  above  and  the 
other  below  the  wound,  or  the  point  of  fracture,  and  having 
passed  the  tails  of  one  through  the  fenestne  of  the  other,  draw 
the  divided  parts  together,  and  confine  them  in  this  position 
by  successive  turns  of  the  roller.  If  necessary,  compresses 
may  be  used,  as  in  the  other  case. 

3.  The  SPLIT  or  TAILED  bandage  consists  of  a  piece  of 
muslin,  or  of  some  other  fabric,  divided  at  its  extremities  into 
a  convenient  number  of  tails,  leaving  the  central  portion  of 
the  band  entire.  Or  a  piece  of  muslin  of  the  proper  dimen- 
sions may  be  selected,  to  each  extremity  of  which  bands  of 
suitable  length  and  width  shall  be  attached.  Constructed 
after  either  method,  this  bandage  is  very  useful  and  conve- 
nient in  confining  dressings. 

A  very  elegant  modification  of  this  bandage  consists  of  a 
number  of  strips,  varying  in  width  from  two  to  four  inches, 
generally,  and  sufficiently  long  to  extend  about  once  and  a 
half  around  the  affected  part,  as  the  leg :  these  strips  are  so 
placed  upon  each  other,  successively,  that  each  has  about 
one-third  of  its  width  covered  by  that  which  succeeds  it  in  the 
order  of  super-position,  commencing  from  above.  The  strips, 
so  arranged,  may  be  attached  in  mass  along  the  centre,  by 
means  of  a  needle  and  thread,  thus  constituting  the  bandage 
of  Pott,  or  they  may  remain  unconnected,  forming  the  band- 
age of  Scultetus ;  the  last  possesses  this  great  advantage  over 
the  other,  that  any  strip,  or  strips,  which  may  have  become 
soiled,  can  readily  be  withdrawn  without  deranging  or  removing 
the  others,  by  simply  pinning  the  fresh  band  to  the  extremity 
of  that  which  is  to  be  rejected,  and  drawing  it  to  the  situation 
occupied  by  the  latter  in  the  bandage. 

These  divided  bandages  form  very  light  retaining  and  com- 
7 


74  COMPOUND    BANDAGES. 

pressing  dressings,  and  present  an  exceedingly  neat  and  ele- 
gant appearance,  when  carefully  adjusted.  That  of  Scultetus 
is  the  one  most  frequently  used. 

4.  The  LACED  bandage  is  made  of  some  more  or  less  elastic 
material,  as  buckskin,  flannel,  or  caoutchouc,  so  shaped  as  to 
correspond  accurately  to  the  contour  of  the  part  to  which  it 
is  to  be  addressed,  and  retained  in  situ  by  means  of  straps 
and  buckles,  or  cords  passed  through  a  series  of  eyelet-holes, 
ranged  along  the  edge  of  each  flap. 

The  laced  bandage  may  be  advantageously  applied  to  any 
part  of  the  surface,  upon  which  a  constant  and  equable 
pressure  will  be  useful ;  its  most  frequent  employment,  how- 
ever, is  around  the  joints,  in  some  chronic  affections,  and  on 
the  leg  in  case  of  varicose  veins. 

A  very  good  substitute,  in  many  instances,  for  the  true 
laced  or  buckled  bandage  will  be  found  in  a  knit  woollen  band 
of  suitable  width,  having  its  two  extremities  firmly  sewed  to- 
gether, thus  forming  a  circlet  somewhat  less  in  circumference 
than  that  of  the  affected  part,  and  capable,  thereby,  of  im- 
parting firm  and  elastic  pressure  around  it.  Or  a  similarly 
shaped  band  of  gum  elastic  cloth  may  be  used,  with  care  to 
protect  the  skin  from  its  irritating  effects  by  lining  it  with 
linen,  or  by  inserting  a  piece  of  linen,  or  silk,  between  the 
skin  and  the  band. 

5.  The  SHEATH  comes  to  hand  already  prepared  for  use,  in 
the  fingers  of  a  glove ;  or  when  a  larger  envelope  is  needed,  it 
may  be  easily  made  after  this  pattern,  of  any  suitable  mate- 
rial.    It  is  serviceable  as  a  means  of  retaining  applications 
upon  the  fingers,  toes,  or  penis,  and  will  be  found  to  be  much 
better  adapted  to   this  purpose  than  a  narrow  roller,  which 
cannot  be  very  neatly  and  conveniently  arranged  upon  these 
parts,  owing  to  their  situation  and  size. 

6.  The  SUSPENSORY  bandage  is  intended  to  afford  support 
and  protection  to  particular  parts,  as  the  nose,  penis,  or  scro- 
tum.    In  its  simplest  forms  its  preparation  is  easy,  being  made 
of  a  piece  of  muslin  or  linen  of  convenient  shape  arid  dimen- 
sions, and  having  bands  or  pieces  of  tape  attached  to  it,  for 
the  purpose  of  retaining  it  in  position.     In  the  stores  in  which 
surgical  apparatus  is  sold,  suspensory  bandages  for  the  scrotum 
will  be  found  very  elegantly  made  of  network. 


MAYOR'S  SYSTEM  OF  BANDAGING.          75 

SECTION   III. 

M.   MAYOR'S  SYSTEM  OF  BANDAGING. 

Struck  with  the  little  change  and  improvement  effected  du- 
ring the  preceding  half-century,  in  that  branch  of  surgery 
which  is  the  subject  of  this  volume,  and  aware  of  the  difficulty 
often  experienced,  in  some  situations  and  circumstances,  in  se- 
curing a  constant  supply  of  the  materials  ordinarily  employed 
in  surgical  dressings,  M.  Mayor,  Chief-Surgeon  to  the  Hospi- 
tal of  Lausanne,  Switzerland,  has  originated  and  developed  a 
new  system,  of  bandaging.  In  the  year  1832,  he  published  a 
treatise  on  this  subject,  entitled,  "  Nouveau  Systeme  de  Deli- 
gation  Chirurgicale,"  which  has  now  passed  through  three  edi- 
tions. The  object  which  M.  Mayor  had  in  view  in  his  inves- 
tigations was,  "  To  discover  some  simple  means,  easy  of  appli- 
cation, always  at  hand,  or  readily  procurable,  and  well  adapted 
to  serve  as  a  substitute  for  charpie,  compresses,  cushions, 
bands,  bandages,  and  ligatures,  which  surgery  requires  for  all 
sorts  of  dressings."  His  researches  and  practical  experience 
have  at  length  led  him  to  the  conclusion,  that  he  has  succeeded 
"in  reducing,  as  far  as  is  practicable,  all  kinds  of  apparatus 
to  their  simplest  form,  by  associating  them  under  one  common 
principle ;  so  that  the  different  parts  of  such  apparatus,  and 
the  materials  for  all  dressings,  will  be  found  to  be  so  common 
and  of  such  nature,  that  they  may  be  always,  or  nearly  always, 
at  the  disposition  of  the  surgeon,  and  of  all  other  persons,  and 
in  the  absence  of  the  practitioner,  may  be  readily  applied, 
after  some  little  instruction,  by  the  first  comer."  (Op.  cit.  3d 
ed.  p.  16  of  the  Introduction.) 

The  whole  '  materiel'  of  M.  Mayor's  system  of  bandaging 
may  be  reduced  to  a  single  square  piece  of  muslin,  or  other 
suitable  fabric ;  or,  in  the  absence  of  this,  an  ordinary  pocket 
handkerchief,  or  a  square  cravat.  From  this  primary  form  he 
makes  four  others,  which  constitute  his  whole  array  of  ban- 
dages ;  these  are  the  oblong  band,  made  by  folding  the  square 
several  times,  until  the  desired  width  be  attained ;  the  trian- 
gular, formed  by  folding  the  square  diagonally ;  the  cravat, 
prepared  from  the  triangle,  as  the  cravat  for  ordinary  wear  is 


76         MAYOR'S  SYSTEM  OF  BANDAGING. 

made ;  and  the  cord,  which  is  merely  the  cravat  rolled  into  the 
form  indicated  by  the  name.  With  these  simple  forms  of  ban- 
dage, M.  Mayor  proposes  to  replace  all  the  ordinary  bands 
and  bandages  of  surgery.  He  contends  that  all  or  nearly  all 
the  indications  which  can  be  fulfilled  by  the  latter,  are  equally 
•well  attained  by  the  former,  while  these  are  always  at  hand 
in  town  and  in  the  country,  at  sea  or  on  land,  in  civil  and  in 
military  practice. 

The  above  is  a  mere  sketch,  an  outline,  of  M.  Mayor's 
plan.  For  a  detailed  account  of  it,  and  for  its  adaptations 
to  particular  cases,  the  reader  is  referred  to  the  treatise  it- 
self. The  system  is  very  simple,  and  its  applications  may  be 
acquired  without  difficulty.  Where  the  object  is  merely  to 
confine  dressings,  or  to  protect  parts  of  the  surface,  or  to 
support  a  limb,  the  simple  means  recommended  and  employed 
by  M.  Mayor  will  probably  be  found  perfectly  efficacious ; 
but  in  the  treatment  of  fractures,  and  in  cases  requiring 
well-regulated  and  firm  compression,  the  author  is  inclined  to 
think  that  they  cannot  be  advantageously  substituted  for  the 
roller  and  other  bandages,  ordinarily  employed,  excepting  as 
temporary  means,  or  in  the  absence  of  the  others.  In  justice 
to  M.  Mayor,  it  must  be  observed,  that  he  himself  admits 
that  there  are  some  circumstances  in  which  his  own  system 
of  bandaging  will  be  found  less  serviceable  than  the  other. 

In  the  different  sections  on  regional  bandaging,  the  author 
will  give  such  of  M.  Mayor's  dressings  as  seem  to  him  to  be 
most  worthy  of  attention.  As  an  admitted  system  for  prac- 
tical adaptation,  it  is  not,  according  to  the  most  accurate 
information  which  the  author  has  been  able  to  obtain,  em- 
ployed in  any  country ;  he  deems  it,  therefore,  superfluous  to 
give  its  details. 


CHAPTER  II. 

REGIONAL    BANDAGING. 

SECTION   I. 
BANDAGES    FOR    THE    HEAD    AND    NECK. 

1.  The  RECURRENT  bandage  of  the  head  is  composed  of  a 
single-headed  roller  about  five  yards  long  and  two  inches 
wide. 

APPLICATION. — The  initial  extremity  of  the  roller  is  placed 
upon  the  lower  part  of  the  forehead,  or  on  the  temple,  or 
occiput,  and  confined  by  a  few  turns  circling  around  the  head 
in  a  line  running  from  just  above  the  eyebrows  to  a  point 
a  little  below  the  occipital  protuberance :  at  the  middle  of 
this  line,  as  at  the  forehead,  the  course  of  the  bandage  is 
reversed,  and  the  reversed  turn  held  by  a  finger  of  the  left 
hand,  while  the  cylinder  of  the  roller  is  carried  over  the  top 
of  the  head  along  the  sagittal  suture,  to  meet  the  circular 
turns  at  the  occiput ;  here  a  reverse  is  made  again,  and  con- 
fined by  an  assistant,  while  the  cylinder  returns  in  an  ellip- 
tical course  to  the  forehead,  where  it  is  retained  upon  the 
first  reverse  by  the  finger  of  the  dresser.  In  this  manner 
successive  reverses  are  made  at  the  forehead  and  occiput,  and 
repeated  returns  of  the  roller  to  and  from  these  points  in 
elliptical  folds,  each  successive  fold  overlapping  about  one- 
third  of  the  preceding,  until  at  length  the  side  of  the  head 
is  completely  covered.  The  other  side  is  covered  in  the  same 
manner  by  successive  folds  similarly  overlaying  each  other, 
and  the  bandage  completed  by  circular  turns  firmly  applied 
over  the  common  points  of  reverse,  in  front  and  behind :  to 
render  the  dressing  still  more  secure,  a  single  turn  of  the 
roller,  commencing  at  the  middle  of  the  last  circular,  laterally, 
may  be  passed  beneath  the  jaw,  to  terminate  at  the  corre- 
sponding point  of  the  circular  on  the  opposite  side.  Pins 
7  *  (77) 


78   BANDAGES  FOR  THE  HEAD  AND  NECK. 


FIG.  19.  should  be  inserted  in  the 

bandage  to  confine  the 
reversed  turns,  at  the 
forehead  and  occiput, 
and  one  also  at  the  ex- 
tremity of  the  roller. 
(Fig.  19.) 

USE. — To  retain  dress- 
ings upon  the  scalp,  and 
to  exercise  moderate 
pressure  where  such  may 
be  required. 

2.  The  T  bandage  of 
the  head  is  composed  of 
a  band  two  yards  long 
and  two  inches  wide,  to 
which  is  attached,  at  right 
angles,  another  strip  of 

the  same  width  and  half  a  yard  in  length.     The  longer  band 
is  then  rolled  into  two  cylinders. 

APPLICATION. — The  dresser,  taking  his  station  in  front  of 
the  patient,  applies  the  bandelette  to  the  top  of  the  head, 
over  which  it  passes  to  the  nape  of  the  neck,  while  the 
longer  portion  of  the  bandage  starting  from  the  middle  of  the 
forehead,  circles  around  the  base  of  the  cranium,  on  each 
side,  to  the  occiput,  where,  just  beneath  the  occipital  protu- 
berance, it  meets  the  vertical  portion  ;  the  latter  having  been 
crossed  and  confined  in  this  position  by  the  other  division  of 
the  bandage,  is  reflected  over  the  vertex  to  the  forehead, 
where  it  is  retained  by  the  folds  of  the  longer  band  which 
expends  itself  in  circular  turns. 

A  double  T  bandage  may  be  used  instead  of  the  single,  if 
more  convenient ;  in  either  case,  the  course  of  the  limbs  of 
the  bandage  may  be  more  or  less  varied  to  suit  particular 
purposes. 

USE. — To  retain  dressings  upon  the  scalp. 
3.  The  four-tailed  bandage  of  the  head  is  formed  of  a  piece 
of  muslin  one  yard  long  and  six  inches  wide,  split  at  each 
extremity  to  within  about  three  inches  of  the  centre. 

Its  APPLICATION  may  be  varied  according  to  the  part  of  the 
nead  upon  which  it  is  intended  particularly  to  act. 


BANDAGES  FOE  THE  HEAD  AND  NECK.    79 

"When  the  wound  is  on  the  forehead,  the  unsplit  portion 
is  applied  there,  and  the  two  upper  tails,  carried  posteriorly, 
are  fixed  at  the  back  of  the  head ; 
the  lower  tails  are  then  fastened 
either  upon  the  vertex  or  beneath 
the  chin,  as  the  surgeon  may  con- 
sider it  most  convenient. 

"  To  confine  a  dressing  upon 
the  summit  of  the  head,  the  poste- 
rior tails,  (a,  fig.  20,)  are  'brought 
down  and  secured  beneath  the 
chin ;  the  anterior  tails  (£>,  &,)  after 
being  carried  to  the  nape  of  the 
neck  and  crossed,  are  fixed  before 
the  throat. 

"  In  applying  it  to  the  nape  of 
the  neck,  the  upper  tails  are  con- 
ducted over  the  forehead,  from  whence,  after  being  made  to 
cross  each  other,  they  are  returned,  and  fastened  at  the  occi- 
put ;  the  lower  tails  pass  round  the  neck."    (Cutler.) 

USE. — As  the  last. 

4.  The  six-tailed,  or  the  bandage  of  Galen,  consists  of  a 
piece  of  muslin  a  yard  long,  and  a  quarter  of  a  yard  wide, 
split  at  each  extremity,  to  within  three  inches  of  the  middle, 
into   three   portions,    of  which   the    central    is    rather   the 
widest. 

APPLICATION. — Place  the  unsplit  portion,  a,  of  the  bandage 
upon  the  top  of  the  head ;  then  folding  the  edges  of  the  cen- 
tral, 5,  tails  inwards,  so  as  to  give  them  a  triangular  form, 
the  base  of  the  triangle  being  at  the  top  of  the  head,  draw 
the  tails  down  over  the  ears  and  tie  their  extremities  beneath 
the  chin.  Reverse  the  relative  position  of  the  anterior  and 
posterior  tails,  bringing  the  latter,  c,  to  the  front,  where  they 
shall  cross  each  other  upon  the  forehead,  and  be  confined : 
while  the  anterior  tails,  d,  are  drawn  round  to  the  occiput, 
are  crossed  beneath  the  protuberance,  and  retained,  as  on  the 
forehead,  by  pins.  (Fig.  21.) 

USE,  as  the  preceding,  over  which  it  possesses  a  supe- 
riority in  being  more  secure,  and  in  covering  a  large  surface 
of  dressing. 

5.  The  fronto-occipital  triangle  of  Mayor,  serves  very  well 


80    BANDAGES  FOE  THE  HEAD  AND  NECK. 

the  purpose  of  a  retaining  bandage.     Its  application  is  very 
simple :   place  the  centre  of  the  base  of  a  triangle  upon  the 


FIG.  21. 


forehead,  just  above  the  superciliary  ridges,  while  the  body 
of  the  triangle  covers  the  top  of  the  head,  the  apex  hanging 
down  upon  the  back  of  the  neck ;  draw  the  tails  around  the 
base  of  the  cranium  to  the  occiput,  cross  them  beneath  the 
protuberance,  and  then  continue  them  respectively  to  the 
temples,  or  forehead,  and  confine  their  extremities  by  pins. 
The  apex  of  the  triangle,  overlapped  at  the  occiput  by  the 
tails,  is  reflected  upon  the  latter,  and,  being  continued  up- 
wards upon  the  body,  is  pinned. 

The  occipito-frontal  and  the  bi-temporal  triangles  are  ap- 
plied in  the  same  manner  as  the  last,  excepting  that  in  one 
case  the  base  of  the  triangle  is  laid  upon  one  of  the  temporal 
regions,  and  in  the  other  upon  the  occiput. 

USES,  the  same  as  of  the  bandage  of  four  tails,  &c.  They 
are  much  more  simple  in  their  application  than  those  hereto- 
fore described,  and  may  very  well  supersede  them. 

6,  The  knotted  bandage  is  composed  of  a  double-headed 
roller  four  yards  long  and  two  inches  wide,  and  of  a  graduated 
compress. 


BANDAGES  FOR  THE  HEAD  AND  NECK.    81 

APPLICATION.  —  Place  the  compress  over  the  wounded 
artery,  and  apply  upon  it  the  body  of  the  roller ;  then  con- 
duct the  heads  around  the  cranium,  one  over  the  brow,  and 
the  other  over  the  occiput,  to  cross  each  other  at  the  opposite 
temple,  whence  they  are  returned  to  the  compress ;  on  reach- 
ing this  point  they  are  twisted  upon  each  other,  and  their 
courses  changed,  one  mounting  over  the  top  of  the  head,  the 
other  descending  beneath  the  chin,  and  both  made  to  cross 
again  at  the  opposite  temple,  after  which  the  same  route  is 
continued  to  the  compress,  where  a  second  twist  is  effected, 
and  the  course  of  the  roller  changed  to  the  horizontal  direc- 
tion, as  at  first ;  again  the  heads  cross  each  other  upon  the 
temple  of  the  sound  side,  the  compress  is  again  reached,  and 
a  third  twist  made,  after  which  the  vertical  course  of  the 
roller  is  resumed,  and  the  bandage  completed  by  a  few  cir- 
cular turns. 

USE. — To  arrest  hemorrhage  from  the  temporal  artery. 
This  somewhat  complicated  bandage  may  be  very  properly 
superseded  by  a  simple  roller,  and  a  compress  which  shall  be 
retained  and  pressed  upon  the  bleeding  vessel  by  a  few  cir- 
cular turns. 

T. -The  four-tailed  bandage  of  the  chin  is  composed  of  a 
strip  of  muslin  a  yard  long  and  three  inches  wide,  and  split 
longitudinally  from  each  extremity,  so  as  to  leave  but  three 
inches  of  the  central  portion  of  the  band  undivided. 

APPLICATION. —  Place  the  middle  of  the  band  upon  the 
chin,  and  carry  the  two  upper  tails,  a,  a, 
along  the  base  of  the  lower  jaw  around  Fl«'  22. 

to  the  nape  of  the  neck,  where  they  are 
crossed,  and  afterwards  conducted  along 
the  base  of  the  cranium  to  the  forehead, 
and  there  secured.  The  lower  tails,  5,  6, 
ascend  over  the  base  of  the  jaw  and  the 
sides  of  the  face,  in  front  of  the  ears,  to 
the  top  of  the  head ;  here  they  cross  each 
other  and  then  descend,  each  on  its  re- 
spective side,  to  the  base  of  the  jaw,  and 
are  confined  beneath  the  chin,  (fig.  22). 

To  increase  the  pressure  exercised  by 
this  bandage,  a  compress  may  be  applied  upon  any  desired 
point. 


I 
82   BANDAGES  FOR  THE  HEAD  AND  NECK. 

USE. — To  retain  dressings  upon  the  chin ;  it  is  also  used  in 
fractures  of  the  lower  jaw,  and  in  dislocations  of  its  condyles 
after  reduction.  For  the  same  purposes  the  bandages  for 
fracture  of  the  lower  jaw,  invented  by  Drs.  Barton  and 
Gibson,  of  this  city,  may  also  be  applied.  (See  Fractures  of 
Lower  Jaw.) 

8.  The  T  bandage  of  the  ear  is  formed  of  a  horizontal 
limb  two  yards  long  and  two  inches  wide,  and  of  a  vertical 
strip  of  the  same  width  and  half  a  yard  in  length. 

APPLICATION.  —  Place  the  vertical  limb  upon  the  ear,  and 
exhaust  the  horizontal  band  in  circular  turns  around  the  base 
of  the  cranium,  passing  just  above  the  ear  and  over  the  fore- 
head and  occiput ;  then  conduct  the  vertical  limb  beneath  the 
jaw,  up  over  the  opposite  side  of  the  face  and  the  top  of  the 
head  to  the  point  whence  it  started,  and  confine  its  extremity 
to  the  horizontal  band. 

USE. — To  serve  as  a  means  of  retaining  dressings  upon 
the  ear. 

9.  The  double  T  bandage  of  the  nose  is  composed  of   a 
band  one  yard  long  and  half  an  inch  wide,  upon  the  middle 
of  which  are  attached  at  moderately  acute  angles,  and  at  the 
distance  of  one  inch  from  each  other,  two  other  strips  half  a 
yard  long  and  of  the  same  width  as  the  first. 

APPLICATION. — The  middle  of  the  horizontal  band  is  placed 
FlG  23  upon  the  upper  lip,  and  its  extremities 

are  conducted  below  the  lobe  of  the  ear 
on  each  side  to  the  nape  of  the  neck, 
where  they  are  tied  in  a  bow-knot. 
The  other  strips  are  then  carried 
obliquely  upwards  over  the  top  of 
the  head,  crossing  each  other  at  the 
root  of  the  nose ;  having  reached  the 
occiput,  they  are  inserted  beneath 
the  horizontal  band,  over  which  they 
are  reverted  upon  the  back  of  the 
head  and  confined,  (fig.  23). 

USE.  —  To  retain  dressings   upon 
the  nose. 

10.  The  sheath  of  the  nose  is  thus  prepared :  "A  piece  of 
linen  is  cut  into  a  triangular  form,  of  a  sufficient  size  to  cover 
the  nose,  with  two  holes  perforated  near  the  inferior  angles 


BANDAGES    FOE    THE    HEAD    AND    NECK.       83 

to  correspond  with  the  nostrils ;  a  triangular  portion  is  cut 
out  from  the  superior  angle  of  this,  the  apex  of  which  looks 
downwards  upon  the  median  line  of  the  nose,  and  the  divided 
edges  are  sewed  together;  thus  a  sort  of  bag  is  formed, 
capable  of  exactly  lodging  the  nose.  To  the  lower  part  of 
the  bag  is  stitched  a  narrow  band,  half  a  yard  long  and  half 
an  inch  wide,  and  to  the  summit  a  second  band  of  like 
dimensions. 

"APPLICATION. — The  bag  is  applied  upon  the  nose ;  the 
surgeon  lays  hold  of  the  inferior  tails,  and,  passing  them  be- 
neath the  ears,  ties  them  in  a  bow  upon  the  nape  of  the  neck ; 
he  then  conducts  the  superior  tail  along  the  sagittal  suture 
as  far  as  the  transverse  band,  under  which  he  passes  it, 
reflecting  the  end  upwards  to  secure  it  upon  the  descending 
portion." 

USE.  —  The  same  as  of  the  foregoing.     (Cutler,  p.  61.) 

11.  A  simple  bandage  for  both  eyes  may  consist  of  a  strip 
of  muslin  two  inches  wide,  and  three  feet  long,  of  which  the 
central  part  is  placed  upon  the  eyes,  and  the  extremities  tied 
upon  the  occiput. 

USE.  —  To  retain  dressings  upon  the  eyes. 

If  the  object  be  merely  to  protect  the  eyes  from  the  light, 
without  exercising  any  compression  upon  them,  it  may  be 
very  conveniently  attained  by  attaching  to  each  side  of  a 
piece  of  muslin,  or  of  green  silk,  of  sufficient  length  and 
width  to  cover  the  eyes,  a  piece  of  tape,  and  then  tying  the 
two  upon  the  occiput.  Or  the  silk,  or  muslin,  may  be  in- 
serted beneath  the  lower  edge  of  a  strip  which  passes  just 
above  the  superciliary  ridges,  around  the  base  of  the  cranium 
to  the  occiput,  where  its  extremities  are  tied.  By  this  latter 
arrangement  cold  or  warm  lotions  may  be  applied  to  the  eyes, 
or  to  one  eye  only,  simply  by  saturating  the  pendulous  flap, 
made  in  this  case  of  linen. 

12.  The  monocle,  or  bandage  for  one  eye,  consists  of  a  sin- 
gle-headed roller  four  yards  long  and  two  inches  wide. 

APPLICATION. — Two  circular  turns  are  made  around  the 
head,  crossing  the  forehead  and  occiput,  after  which  the  course 
of  the  roller  is  somewhat  depressed,  traversing  the  nape  of  the 
neck  and  passing  beneath  the  ear  of  the  affected  side,  to  as- 
cend obliquely  towards  the  affected  eye,  which  it  crosses  dia- 
gonally j  continuing  the  same  direction,  it  mounts  over  the  fore- 


84   BANDAGES  FOR  THE  HEAD  AND  NECK. 


FIG.  24. 


head  and  side  of  the  head,  crossing  the  top  of  the  parietal  su- 
ture, to  descend  again  to  the  nape  of  the 
neck,  from  which  point  it  renews  its  course, 
as  just  described.  Two  or  three  succes- 
sive turns  are  thus  made  obliquely  around 
the  head,  in  the  form  of  doloires  present- 
ing inferiorly,  a,  a,  a;  arid  the  bandage  is 
then  terminated  by  circular  sweeps  around 
the  forehead  and  occiput,  5,  6,  (fig.  24.) 

USE. — To  confine  dressings  upon    the 
eye. 

13.    The  invaginated  bandage  for  the 
lip  consists  of  a  double-headed  roller,  from 
two    to    three    yards    long,    and   three- 
fourths  of  an  inch  wide,  and  of  two  small 
compresses. 

APPLICATION. — Place  the  body  of  the  roller  upon  the  fore- 
head, and  conduct  the  heads,  on  each  side  respectively,  around 
the  cranium  to  the  nape  of  the  neck  ;  cross  them  at  this  point, 
and  then  carry  them  beneath  the  ears  to  the  upper  lip,  over 
the  compresses  previously  placed  near  to,  and  parallel  with, 
the  edges  of  the  wound  ;  make  a  longitudinal  slit  in  one  of  the 
tails,  opposite  the  centre  of  the  lip,  and  through  it  pass  the 
other  head;  make,  very  gently  and  gradually,  a  sufficient 

strain  upon  the  heads  of  the 
roller,  and  conduct  them  again 
to  the  nape  of  the  neck,  and 
thence  to  the  forehead ;  repeat 
this  process  until  the  requisite 
support  is  acquired  for  the  lip, 
and  then  confine  the  extremities 
of  the  roller,  in  the  customary 
manner,  (fig.  25). 

USE. — To  approximate  the 
edges  of  transverse  wounds  of 
the  lip,  and  to  give  support,  also, 
to  the  hare-lip  suture,  or  to  re- 
place it  after  the  withdrawal  of 
the  pins. 

14.  A  sheath  for  the  tongue  has  been  contrived  by  Pibrac, 
to  serve  as  a  means  of  confining  it,  in  some  measure,  when 


FIG.  25. 


BANDAGES    FOR    THE    HEAD    AND    NECK.       85 

wounded*  It  consists  "  of  a  little  purse,  a,  for  enclosing  the 
point  of  the  tongue,  having  at- 
tached to  its  base  two  silver 
wires,  which  are  to  be  bent  un- 
derneath the  chin  ;  to  this  frame 
two  ribbons  are  appended,  which 
pass  from  the  chin  backwards, 
beneath  the  ears,  to  the  nape  of 
the  neck,  and  thence  ascend  to 
be  tied  across  the  forehead." 
(Velpeau,  op.  cit.,  vol.  i.  p.  198.) 
-(Fig.  26.) 

15.  The  mask  for  the  face  is 
made  of  a  piece  of  muslin,  or 
linen,  as  large  as  the  face  itself, 
having  apertures  cut  in  it  to  cor- 
respond with  the  eyes,  nostrils, 
and  mouth,  and  a  strip  of  mus- 
lin attached  to  each  angle. 

APPLICATION.  —  Place  the 
mask  upon  the  face  so  that  the 
apertures  shall  be  accurately 
adapted  to  the  parts  for  which  they  were  intended ;  carry  the 
superior  strips  along  the  base  of  the  cranium  to  the  nape  of 
the  neck,  cross  them  there,  then  conduct  them  round  to  the 
chin  and  tie  them  upon  the  mask ;  cross  the  inferior  bands 
also  upon  the  nape  of  the  neck  and  terminate  the  bandage  by 
knotting  them  upon  the  forehead. 

USE. — To  serve  as  a  simple  covering  to  the  face,  and  to 
confine  dressings  upon  it. 

16.  The  cervical  cravat  of  Mayor  consists  simply  of  a  tri- 
angular piece  of  muslin,  or  an  ordinary  handkerchief,  folded 
to  the  form  of  a  cravat. 

APPLICATION. — Place  the  centre  of  the  cravat  opposite  the 
larynx,  the  side  of  the  neck,  or  the  back  of  the  neck,  as  may 
be  most  proper,  and  tie  its  extremities  at  the  opposite  point. 

USE. — To  retain  dressings. 

A  simple  piece  of  muslin  or  flannel  is  often  used  as  a  re- 
taining band,  in  this  region.  The  objection  to  such  an  appli- 
cation, as  commonly  prepared,  is  that  it  soon  becomes  rolled, 
ind  ceases  to  cover  the  part  properly.  This  difficulty  may  be 


86   BANDAGES  FOE  THE  HEAD  AND  NECK. 


FIG.  27. 


obviated  by  a  simple  method :  take  a  piece  of  flannekor  mus- 
lin, rather  longer  than  the  circumference  of  the  neck,  and 
wide  enough  to  cover  it  completely ;  fold  it  upon  itself  in  its 
length,  and  cut  from  its  anterior  border,  while  folded,  a  trian- 
gular piece,  of  which  the  base  presents  upwards ;  then  sew  the 
cut  edges  together,  and  unfold  the  band,  which  has  thus  ac- 
quired the  form  of  a  common  stock,  and  will  not  become  corded 
when  worn  upon  the  neck.  Its  extremities  should  overlap 
each  other,  and  be  confined  by  pins,  posteriorly. 

17.  The  flexor  bandage  of  the  neck,  which  appears  to  be 

the  most  secure,  and  at  the  same  time  the  most  simple  and 

convenient,  is  the  one  described  by  Yelpeau,  (op.  cit.  p.  203). 

It  consists  of  a  strong  muslin  cap  for  the  head ;  a  band  of 

stout  material,  three  or  four 
inches  wide  and  about  three- 
fourths  of  a  yard  long ;  a  roller 
two  yards  in  length,  and  a  circu- 
lar bandage  for  the  chest,  (to  be 
described  in  the  next  section,) 
with  shoulder  and  pelvic  strips 
attached. 

Its  mode  of  application  varies 
somewhat  with  the  indication  it 
is  intended  to  fulfil. 

If  it  be  employed  in  the  treat- 
ment of  a  transverse  wound  of 
the  neck,  for  instance,  it  is  thus 
applied :  Fix  the  cap  firmly  to 
the  head  by  means  of  a  band 
passing  under  the  chin ;  place 
the  undivided  portion  of  the 
strong  band  above-mentioned 
upon  the  top  of  the  head,  its  ex- 
tremity reposing  upon  the  occi- 
put, while  the  split  portion  of  the 
same  band  hangs  down  over  the 
face  upon  the  chest;  secure  it 
firmly  upon  the  head,  in  this  po- 
sition, by  several  circular  turns 
of  the  roller,  and  then,  having 
flexed  the  head  to  the  requisite 


BANDAGES  FOR  THE  HEAD  AND  NECK. 


8T 


degree  upon  the  anterior  face  of  the  neck,  pin  the  tails  of  the 
band,  at  a  convenient  distance  from  each  other,  to  the  tho- 
racic bandage  which  has  been  previously  applied  to  the 
chest. 

The  same  may  be  used  as  a  dividing  bandage  by  simply 
reversing  the  relative  positions  of  the  extremities  of  the  band, 
the  undivided  end  being  placed  upon  the  forehead,  and  the 
split  portion  hanging  down  over  the  occiput,  so  that  the  head 
may  be  flexed  backwards  on  the  neck,  or  maintained  upright, 
and  so  retained  by  confining  the  tails  of  the  band  upon  the 
posterior  aspect  of  the  thoracic  bandage.  Thus  applied,  it 
will  be  of  advantage  in  the  treatment  of  burns,  &c.,  &c.,  upon 
the  front  of  the  neck. 

Again,  a  lateral  flexion  maybe  given  to  the  head,  as  is  seen 
in  the  annexed  figure,  (fig.  27). 

18.  Professor  Jb'rg's  apparatus  for  the  treatment  of  "  wry- 
neck" consists  of  a  pair  of  leather  stays  for  the  chest,  and  of 
a  band  or  strong  circlet  for  the  head.  On  the  centre  of  the 

FIG.  28. 


88         BANDAGES  FOR  THE  TRUNK. 

stays,  in  front,  is  a  ratchet-wheel,  having  the  edge  serrated  in 
such  a  way  as  that  it  revolves  only  in  one  direction  upon  its 
axis,  the  reverse  motion  being  prevented  by  a  spring  pressing 
against  the  teeth ;  a  band  passes  upwards  from  the  wheel  to 
be  attached  to  the  fillet  opposite  the  side  of  the  head ;  then 
by  turning  the  wheel  by  means  of  a  key,  a,  the  side  of  the 
head  is  approximated  to  the  sternum,  so  as  to  counteract 
or  overcome  the  opposing  muscles  of  the  affected  side, 
(fig.  28). 

This  instrument  may  be  employed  in  those  cases  of  torti- 
collis in  which  a  considerable  degree  of  force  has  to  be  exerted 
and  continued  for  a  length  of  time  ;  where  less  power  is  requi- 
site, the  simpler  bandage  last-mentioned  may  be  used. 


SECTION   II. 
BANDAGES    FOR    THE    TRUNK. 

1.  The  dorso-thoracic  triangle.     (Mayor.) 
APPLICATION. — Place  the  base  of  the  triangle  upon  the 

anterior,  or  the  posterior,  aspect  of  the  chest,  as  the  seat  of 
the  injury  may  require,  and  tie  the  tails  upon  the  thorax  either 
before  or  behind,  while  the  apex  is  allowed  to  repose  over  one 
of  the  shoulders,  being  attached  to  the  base  of  the  triangle 
through  the  intermedium  of  a  band,  if  it  be  not  sufficiently 
long  of  itself  to  reach  this  point. 

USE. — To  retain  dressings  upon  the  anterior  or  posterior 
face  of  the  chest. 

2.  Circular  bandage  with  straps,  for  the  thorax. 
COMPOSITION. — A  strong   towel,  or   an    oblong   piece   of 

muslin,  folded  upon  itself  to  acquire  sufficient  strength  ;  and  a 
band  two  feet  long  and  four  inches  wide,  split  from  one  end 
through  almost  its  entire  length. 

APPLICATION. — The  napkin  is  wrapped  around  the  chest, 
its  extremities  overlapping  and  pinned ;  the  undivided  ex- 
tremity of  the  band  is  then  attached  in  the  same  manner  to 
the  middle  of  this  posteriorly,  and  its  tails  brought  to  the 
front,  one  over  each  shoulder,  and  pinned  likewise  to  the 
same. 

Instead  of  the  split  band,  a  triangular  piece  of  muslin  may 


BANDAGES  FOR  THE  TRUNK. 


89 


be  used  for  the  scapulary,  by  applying  its  base  to  the  back 
of  the  neck,  and  attaching  the  apex  to  the  thoracic  bandage 
posteriorly,  while  the  tails  cross,  one  over  each  shoulder,  to 
be  pinned  to  the  bandage  in  front. 

Again,  the  thoracic  band  itself  may  be  rendered  more  effi- 
cient, if  a  constant  compression  be  desirable,  by  substituting 
straps  and  buckles,  or  by  lacing  it,  instead  of  securing  it  by 
means  of  pins. 

USE.  —  To  confine  dressings  upon  the  thorax ;  to  restrain 
the  motions  of  the  chest  in  wounds  of  this  part,  or  in  case 
of  fracture  of  the  ribs ;  and  to  secure,  by  the  aid  of  com- 
presses, the  coaptation  of  the  fragments,  in  the  latter  injury. 

3.  The  compressive  bandage  of  Velpeau,  consists  of  a 
roller  seven  or  eight  yards  long  and  three  inches  wide. 

APPLICATION.  —  Let  about  two  feet  of  the  free  end  of  the 
roller  hang  over  the  shoulder  of  the  sound  side,  down  the 
back  ;  then  carry  the  cylinder  over  the  front  of  the  chest, 
below  the  axilla  of  the  affected  side,  to  surround  the  thorax 

FIG.  29. 


90 


BANDAGES    FOR    THE    TRUNK. 


•with  several  circular  turns,  and  to  confine  the  pendant  portion 
of  the  roller  ;  ascend  the  chest  gradually  by  circular  folds, 
each  one  successively  overlapping  ahout  two-thirds  of  the 
preceding ;  pass  the  bandage  around  the  axillae  in  the  form 
of  the  figure  8,  and  terminate  by  circular  folds ;  now,  finally, 
raise  the  pendant  extremity  of  the  roller,  and  crossing  it  over 
the  shoulder  of  the  affected  side,  attach  it  to  the  inferior 
circular  turns  by  pins  (fig.  29). 

USE  :  as  of  the  preceding ;  it  has  the  advantage  over  the 
ordinary  circular  bandages  of  the  thorax,  in  being  more 
secure,  and  less  easily  deranged. 

4.  The  crossed  bandage  of  the  chest,  or  the  figure  8 
bandage  of  the  shoulders. 

COMPOSITION.  —  A  roller  five  yards  long  and  two  and  a 
half  inches  wide :  cotton,  or  folded  muslin,  to  protect  the 
surface  at  the  axillae,  and  compresses  if  indicated. 

APPLICATION.  —  If  the  object  be  to  approximate  the 
shoulders  to  the  sternum,  the  folds  of  the  bandage  should 
cross  in  front  of  the  chest.  Place  the  free  extremity  of  the 

roller  in  one  of  the 
axillae,  and  pass  two 
or  three  circular  turns 
around  the  thorax ; 
then,  the  axillae  being 
protected  by  the  cot- 
ton, and  the  shoulders 
drawn  towards  the 
sternum,  by  an  as- 
sistant, if  necessary, 
—  traverse  the  axillae, 
say  of  the  left  side, 
and  ascend  over  the 
shoulder  from  behind 
forwards ;  cross  the 
front  of  the  chest  to 
the  right  axilla;  mount 
over  the  right  shoulder 
from  its  posterior  to 
its  anterior  face ;  de- 
scend obliquely  over 
the  front  of  the  chest 


FIG.  30. 


BANDAGES  FOB  THE  TRUNK.         91 

to  the  left  axilla,  whence  repeat  the  same  course  as  before, 
until  four  or  five  folds  have  been  laid  upon  each  shoulder, 
each  successive  fold,  in  approaching  from  the  shoulder  to  the 
neck,  overlapping  about  two-thirds  of  the  preceding.  Ter- 
minate the  bandage  in  circular  sweeps  around  the  thorax. 

(Kg- .80.) 

If  it  be  desired  to  draw  the  shoulders  from  the  breast,  it 
can  be  effected  by  simply  reversing  the  course  of  the  roller, 
crossing  the  shoulders  from  before  backwards. 

USE. — To  aid  in  the  treatment  of  wounds  of  the  chest,  by 
approximating  or  withdrawing  the  shoulders  from  the  sternum, 
as  may  be  indicated  by  the  situation  of  the  wound ;  to  effect 
pressure  upon  the  clavicular  regions,  and  upon  the  sternum, 
or  back,  or  in  the  axillae. 

5.  Suspensory  for  the  breast. 

COMPOSITION. — Double  twice  upon  itself  a  piece  of  linen 
ten  inches  square,  and  from  the  free  extremity  of  each  folded 
border  cut  a  triangular  portion,  of  which  the  apex  shall  ter- 
minate in  the  fold ;  then  open  the  square  and  sew  the  divided 
edges  together ;  thus,  a  concave  cap  is  formed  adapted  to  the 
globular  conformation  of  the  breast.  Attach  a  piece  of  tape, 
or  a  band  of  muslin,  to  each  angle  of  the  square. 

APPLICATION. — Place  the  cap  upon  the  mamma  and  confine 
it  in  situ  by  tying  the  two  superior  bands  around  the  neck, 
and  the  inferior  around  the  chest  below  the  gland. 

USE. — To  support  the  mamma,  and  to  retain  dressings 
upon  it. 

6.  The  triangle-cap  for  the  breast  is  applied,  with  the  base 
passing  just  below  the  mamma,  the  tails  knotted  on  the  poste- 
rior part  of  the  chest,  and  the  apex  ascending  upon  the  gland 
to  cross  over  the  shoulder  of  the  same  side,  and  be  confined 
to  the  tails,  directly  or  through  the  intervention  of  a  strip  of 
muslin,  or  tape. 

USE. — As  of  the  last. 

7.  The  compressive  bandage  of  one  breast. 

It  will  be  found  exceedingly  difficult,  if  not  impossible,  en- 
tirely to  envelope  one  of  the  mammary  glands  by  means  of  a 
roller,  which  shall  be  so  applied  as  not  to  become  deranged 
very  soon,  and  yet  to  leave  the  sound  breast  free ;  but  such  a 
concurrence  of  conditions  is  frequently  desirable.  To  fulfil 
these  indications  the  following  bandage  may  be  ^mployed. 


92         BANDAGES  FOB  THE  TRUNK. 

COMPOSITION. — The  same  as  of  the  suspensory  of  the  mam- 
ma, described  above,  the  degree  of  concavity  of  the  cap  being 
proportioned  to  the  volume  and  convexity  of  the  gland ;  gra- 
duated compresses. 

APPLICATION. — Place  the  compresses  upon  such  points  of 
the  gland  as  require  most  pressure,  and  cover  the  whole  with 
the  cap ;  then  pass  one  of  the  superior  bands  over  the  shoul- 
der of  the  sound  side,  and  the  other  beneath  the  axilla  of  the 
side  affected  (the  surface  being  protected,  if  necessary,  by  cot- 
ton interposed  between  the  bands  and  the  skin) ;  knot  the  two  : 
draw  the  inferior  bands  around  the  chest,  beneath  the  breasts, 
and  tie  them  either  in  front  or  behind.  The  degree  of  pres- 
sure exercised  upon  the  diseased  mamma  can  be  easily  regu- 
lated by  the  size  of  the  compresses,  and  the  force  with  which 
the  bands  shall  be  drawn. 

USE. — To  effect  a  regulated  compression  of  the  breast,  in 
chronic  induration  or  engorgement  of  this  organ,  and  to  obli- 
terate the  canals  of  sinuses,  if  such  exist. 

8.  The  straight  jacket  is  a  garment  made  of  strong  but  light 
canvass,  extending  from  the  root  of  the  neck  to  the  upper 
third  of  the  thigh.  It  is  closed  in  front,  and  has  straps  and 
buckles  attached  to  its  posterior  borders,  or  eyelet  holes 
worked  in  them.  Along  its  inner  surface  sleeves  are  firmly 
attached,  throughout  their  entire  length,  open  above  but  closed 
below,  and  at  the  proper  distance  from  each  other  to  corres- 
pond with  the  arms  ;  opposite  the  wrists,  a  slit  may  be  made 
through  the  jacket,  to  enable  the  professional  attendant  to 
feel  the  pulse  of  the  patient;  shoulder  straps  should  be  attached 
to  the  superior  border  of  the  canvass,  to  prevent  the  possibility 
of  the  jacket  slipping  down,  from  the  efforts  of  the  patient. 

APPLICATION. — Insert  the  arms  of  the  patient  into  the 
sleeves,  and  having  -nicely  adapted  the  jacket  to  the  body, 
draw  its  borders  together  behind,  and  confine  them  by  the 
straps  and  buckles,  or  by  lacing. 

USE. — To  assist  in  the  restriction  of  the  insane,  or  of  those 
who  are  unmanageable  from  any  cause. 

A  very  convenient  substitute  for  the  straight  jacket,  and 
one  which,  while  it  is  equally  secure,  is  less  irksome  to  the  pa- 
tient, may  be  found  in  a  pair  of  leather  mittens,  made  suffi- 
ciently loose  to  be  easy  to  the  hand,  and  slit  at  the  wrist  so 
that,  after  the  hand  is  introduced,  one  border  of  the  wrist- 


BANDAGES  FOE  THE  TRUNK.         93 

band,  in  which  a  fenestra  has  been  made,  shall  overlap  the 
other,  and  be  confined  upon  it  by  an  iron  loop,  which  passes 
through  the  fenestra ;  then  insert  through  the  loop  on  each 
wrist  a  leather  strap,  having  a  buckle  at  one  end,  and  enclose 
the  waist  therewith. 

9.  The  body-bandage  of  the  abdomen  consists  of  a  piece  of 
muslin  or  linen  folded  to  an  oblong  shape,  a  foot  or  more  in 
width,  and  long  enough  to  envelope  the  abdomen  ;  and  of  two 
narrow  straps  sewed  to  its  inferior  posterior  margin,  to  serve 
as  thigh-straps. 

APPLICATION. — Place  the  centre  of  the  bandage  upon  the 
median  line  of  the  loins,  and  bring  its  extremities  round  to  the 
front  of  the  abdomen,  where  they  should  be  overlapped  and 
pinned;  then  draw  the  thigh-straps  to  the  front  along  the 
perineum,  and  attach  them  to  the  anterior  part  of  the  bandage. 

USE. — To  retain  surgical  dressings,  to  give  support  to  the 
walls  of  the  abdomen,  and  to  exercise  pressure  thereon,  as  in 
umbilical  hernia;  in  the  latter  case  a  graduated  compress 
should  be  employed  to  assist  the  compressive  action  of  the 
bandage. 

There  are  many  cases,  however,  in  which  a  bandage  formed 
of  a  plain  piece  of  muslin,  will  not  support  the  walls  of  the 
abdomen  sufficiently  well.  In  order  to  effect  this  object  more 
satisfactorily,  an  apparatus  should  be  made  resembling  the 
corsets  of  ladies ;  adapted  to  the  conformation  of  the  belly, 
and  rendered  firm,  and  yet  elastic,  by  the  introduction  into  its 
folds  of  strips  of  whalebone.  Its  inferior  margin  in  front 
should  be  curved,  to  correspond  with  the  shape  of  the  lower 
part  of  the  abdominal  parietes,  so  that,  by  being  properly 
laced  in  front  or  behind,  either  a  uniform  pressure,  diffused 
equally  over  the  whole  surface,  can  be  effected,  or  a  more  par- 
tial action  may  be  exerted  in  a  particular  "direction. 

An  apparatus  of  this  sort  will  be  found  applicable  to  many 
cases :  in  umbilical  hernia,  in  ascites,  in  pregnancy,  and  in 
other  instances  of  abdominal  distension,  a  very  agreeable  sup- 
port will  be  afforded  by  its  use ;  and  very  considerable,  if  not 
complete,  relief  will  be  given  to  symptoms  simulating,  and 
sometimes,  perhaps,  depending  upon  prolapsus  uteri,  or  other 
displacements  of  this  organ ;  such,  for  example,  as  dragging 
pain  and  weight  in  the  pelvis,  a  sense  of  exhaustion,  of  "  fall- 
ing-in  of  the  belly,"  of  faintness,  &c.,  &c. 


94 


BANDAGES    FOR    THE    TRUNK. 


FIG.  31. 


The  annexed  drawing  of  an  apparatus  of  this  kind  is  copied 
from  Velpeau,  (fig.  31). 

10.  The  posterior 
pelvic    triangle,    of 
applied 


Mayor,  is 
•with  the  base  along 
the  top  of  the  sacrum, 
and  the  apex  de- 
pending over  this 
bone :  the  tails  are 
brought  round  to  the 
front  of  the  abdomen 
and  knotted,  and  the 
apex  passed  between 
the  thighs,  along  the 
perineum,  and  pubis, 
to  be  attached  to  the 
tails. 

USE.  —  To  retain 
dressings  upon  the 
sacrum  and  peri- 
neum. 

11.  The  anterior 
pelvic  triangle  has 
the  base  applied  to  the  abdomen  just  above  the  pubis,  while 
the  apex  passes  from  before  backwards  between  the  thighs,  to 
be  attached  to  the  tails  which  are  tied  upon  the  sacrum. 

USE. — To  confine  applications  to  the  pubis  or  genitals,  or 
simply  to  cover  these  parts. 

12.  The  triangular  bandage  for  the  groin  is  composed  of  a 
piece  of  muslin  of  a  triangular  shape,  and  sufficiently  large  to 
extend  from  the  median  line  of  the  abdomen  to  the  fold  of 
the  groin :  to  the  base  is  sewed  a  band  long  enough  to  pass 
around  the  abdomen,  and  to  the  apex  another  band  of  about 
the  same  length. 

APPLICATION. — Place  the  triangle  upon  the  groin,  the  apex 
pointing  downwards ;  tie  the  superior  band  around  the  waist, 
and  bring  the  inferior  round  the  thigh,  from  before  backwards, 
to  be  pinned  to  the  first,  opposite  the  centre  of  the  base  of 
the  triangle.  (Fig.  32.) 

USE. — To  retain  dressings  upon  the  groin. 


BANDAGES    FOR    THE    TRUNK. 


95 


13.  The  cruro-inguinal  triangle,  of  Mayor. 
APPLICATION. — Dispose  the  base,  «,  a,  so  that  it  shall  run 
obliquely  from  the  summit  of  the  affected  groin  to  the  edge 
of  the  iliac  crest  of  the  opposite  side,  the  apex  pointing  ob- 
liquely downwards  along  the  groin ;  wrap  the  inferior  tail 
around  the  thigh  of  the  affected  side,  from  behind  forwards, 
arid  pin  its  extremity  to  the  body  of  the  triangle,  at  b;  to  the 
superior  tail  attach  a  band,  £,  and  carry  this  around  the  loins 
to  the  affected  side,  down  along  the  fold  of  the  groin,  d,  d, 
crossing  the  body  of  the  triangle,  and  the  apex, — pinning  the 

latter  to  it, —  around  the 

FlG-  32-  posterior    and   outer  as- 

pects  of  the  thigh,  to  be 
confined  at  e.    (Fig.  33.) 
USE. — As  of  the  last. 


FIG.  33. 


14.   The  spica  of  the  groin. 

APPLICATION. — Place  the  initial  extremity  of  a  roller  seven 
yards  long  and  two  inches  wide,  upon  the  sound  side  of  the 
pelvis,  between  the  anterior  spines  of  the  ilium,  and  confine 
it  by  circular  turns  passing  around  the  body,  from  before 
backwards.  After  having  made  two  or  three  circular  turns, 
carry  the  head  of  the  roller  obliquely  downwards  over  the 
groin  affected,  around  the  posterior  aspect  of  the  thigh  to  the 
ilium  again,  then  across  the  groin  to  the  opposite  side  of  the 
pelvis,  from  which  it  returns  to  the  affected  side  and  repeats 
the  same  process  several  times,  terminating  at  length  by  one 


96  BANDAGES    FOR    THE    TRUNK. 

or  two  circular  turns.  Each  successive  layer  of  the  roller 
should  leave  exposed  about  one-third  of  that  which  preceded 
it ;  see  fig.  16,  e,  e. 

USE. — To  confine  dressings  upon  the  groin,  and  to  exercise 
some  degree  of  compression  upon  it,  as  in  chronic  glandular 
enlargements  and  indurations. 

15.  The  cruro-inguinal  cravat,  of  Mayor,  will  be  found  a 
very  good  substitute  for  the  spica  just  described,  and  much 
more  simple  in  its  application. 

Place  one  end  of  the  cravat  upon  the  affected  groin,  over 
a  compress,  or  not,  and  conduct  the  remainder  downwards, 
along  the  groin,  to  pass  between  the  genitals  and  the  thigh, 
and  thus  gain  the  posterior  face  of  the  limb  ;  ascend  obliquely 
upwards  and  outwards  over  the  thigh,  cross  the  affected 
groin,  and  the  end  of  the  cravat  already  spoken  of,  to  the 
iliac  crest  of  the  opposite  side ;  wind  around  the  loins  to  the 
ilium  of  the  affected  side,  pass  obliquely  downwards  along  the 
groin,  and  gain  the  external  face  of  the  thigh,  as  before,  where 
the  extremity  is  to  be  pinned. 

16.  The  spica  for  both  groins. 

APPLICATION. — Place  the  initial  end  of  a  roller,  ten  yards 
long  and  two  inches  wide,  upon  the  pelvis,  as  in  the  single 
spica,  and  confine  it  by  circular  turns  running  around  the 
pelvis  from  right  to  left,  (this  being  the  most  convenient 
course  in  practice) ;  having  reached  the  left  side,  descend 
along  the  outer  face  of  the  thigh,  around  it  posteriorly,  and 
so  gain  the  groin  ;  then  carry  the  roller  upwards  over  the 
groin  to  the  ilium  of  the  same  side,  and  thence  around  the 
loins  to  the  opposite  groin ;  descending  this  obliquely,  pass 
the  bandage  between  the  genitals  and  the  thigh,  and  around 
the  limb  to  mount  over  its  outer  face ;  cross  the  right  groin, 
and  the  lower  part  of  the  abdomen  to  the  left  ilium,  and  then 
wind  around  the  left  groin,  and  so  proceed  as  before.  After 
several  turns  have  been  made  in  this  manner,  terminate  the 
bandage  by  a  few  circulars  around  the  pelvis. 

USE. — To  effect  pressure  upon  both  groins. 

The  same  object  may  be  attained  by  the  use  of  cravats. 

17.  The  double  T  bandage  of  the  pelvis  is  prepared  from 
a  band    two   or   three   yards    long   and    three    inches  wide, 
having  sewed  to  it  at  right  angles,  and  at  a  convenient  dis- 
tance from  one  extremity,  two  other  strips,  distant  from  each 


BANDAGES    FOR    THE    TRUNK. 


97 


ovWi  ill/out  two  inches,  each  being  an  inch  wide  and  half  a 
ya/cf  iong. 

APPLICATION. — Place  the  horizontal  band  so  that  the  ver- 
tical strips  shall  depend,  one  on  each  side  of  the  median  line 
of  the  sacrum.  Confine  the  first  by  two  or  three  circular 
turns  around  the  body,  and  draw  the  vertical  bands  forwards 
between  the  thighs,  crossing  them  upon  the  perineum,  to  be 
attached  to  the  horizontal  strip  in  front. 

USE. — To  retain  applications  made  to  the  anus,  vagina,  or 
perineum. 

Instead  of  two  vertical  pieces,  a  single  strip  may  be  used, 
half  a  yard  long  and  as  wide  as  both  the  others  combined,  slit 
at  its  free  extremity  to  near  the  horizontal  portion. 

18.  The  suspensory  of  the  scrotum  may  be  made  of  two 
pieces  of  linen  or  muslin,  or  of  network,  of  a 
size  varying  according  to  the  volume  of  the 
scrotum.     In  general,   they  should  be  each 
"  six  inches  long  and  four  wide ;  the  pieces 
being  laid  together  with  exactness,  two  por- 
tions are  cut  out  curvilinearly,  as  shown  in 
the  wood  cut  (fig.  34),  by  dotted  lines ;  the 
divided  edges  from  a  to  6  being  sewed  to- 
gether, a  sort  of  bag  is  formed,  which  pre- 
sents at  the  middle  of  its  upper  part  an  opening,  /  (fig.  35), 
through  which  the  penis  passes.     A 
belt,  0,  two  inches  wide  and  rather 
longer  than  is  requisite  to  encircle 
the  body  twice,  is  then  sewed  along 
the  upper  edges  of  the  bag,  as  from 
c  to  d  (fig.  34) ;  to  the  superior  bor- 
der of  this  belt,  at  about  two  inches 
each    way   from    the    centre,    are 
attached  two  small  loops  of  tape  or 
riband,  d,  d,  fig.  35,  and  about  as 
far  again  from  the  centre  two  mould- 
buttons,  0,  e. 

"  Two  bandelettes  are  next  fas- 
tened to  the  lower  angle  of  the  bag, 
each  about  half  a  yard  long,  with 
two  button-holes  near  their  free  extremities. 

"APPLICATION.     The  penis  being  engaged  in  the  triangular 
9 


FIG.  35. 


98 


BANDAGES    FOR    THE    TRUNK. 


FIG.  36. 


opening,  /,  of  the  bag,  and  the  scrotum  perfectly  enveloped, 
the  belt  is  carried  round  the  pelvis,  and  being  returned 
through  the  loops,  d.  c?,  is  tied  above  the  pubis ;  the  two 
bandelettes  are  then  passed  between  the  thighs,  to  ascend 
from  the  perineum  along  the  inferior  borders  of  the  glutei 
muscles,  and  buttoned  to  the  belt  in  front,  e,  e. 

"  USE. — To  support  and  confine  dressings  upon  the  scro- 
tum ;  to  serve  also  as  points  of  attachment  for  other  appa- 
ratus. It  is  chiefly  employed  in  the  treatment  of  swelled 
testicle,  hydrocele,  and  irreducible  scrotal  hernia."  (Cutler, 
pp.  101-2.) 

19.  The  suspensory  triangle  of  Mayor. 
APPLICATION. — Pass  a  cravat  around  the   abdomen   and 

pelvis,  and  knot  it  securely.  Ap- 
ply the  base  of  a  triangle  to  the 
under  part  of  the  scrotum  at  its 
origin,  and  draw  the  tails  upwards 
in  front  of  the  cravat,  to  be  re- 
flected over  its  superior  edge,  be- 
tween it  and  the  abdomen,  and  tied 
as  represented  in  the  annexed  fi- 
gure (fig.  36).  Carry  the  apex  of 
the  triangle  upwards,  inserting  it 
behind  the  transverse  portion  of  the 
tails  (see  fig.  86),  between  the  abdo- 
men and  the  girdle,  to  be  reflected 
forwards  over  the  superior  border 
of  the  latter  and  pinned  to  it. 
USE. — The  same  as  of  the  last. 

20.  Bandage  for  the  penis. 

It  is  requisite  sometimes  to  make  use  of  some  means  for 
confining  applications  upon  the  penis.  For  this  purpose  a 
sheath  is  the  most  convenient  covering.  When,  however,  a 
certain  degree  of  compression  is  wished  for,  the  organ  should 
be  enveloped  in  circular  and  reversed  turns  of  a  piece  of  tape, 
or  some  very  narrow  strip  prepared  at  the  time. 

For  the  compressive  bandage  of  the  scrotum,  see  remarks 
in  the  section  on  "adhesive  plaster." 


BANDAGES  FOR   THE   UPPER   EXTREMITIES.       99 

SECTION   III. 
BANDAGES    FOR    THE    UPPER    EXTREMITIES. 

1.  The  axillo-clavicular  cravat,  of  Mayor. 
APPLICATION. — Place  the  centre  of  the  cravat  upon  the 

axilla,  and  draw  the  tails  obliquely  upwards  over  the  chest, 
one  in  front  and  the  other  behind,  to  be  knotted  together 
upon  the  clavicle  of  the  opposite  side. 

USE. — To  confine  dressings  in  the  axilla. 

This  may  be  varied  a  little,  and  still  fulfil  the  same  end, 
by  crossing  the  tails  of  the  cravat  upon  the  shoulder  of  the 
affected  side, — the  centre  being  in  the  axilla,  as  before, — and 
then  conducting  them,  one  in  front  of  and  the  other  behind 
the  chest,  to  the  axilla  of  the  sound  side,  where  they  are  to 
be  secured. 

2.  The  compound  bis-axillary  cravat  is  applied,  by  arrang- 
ing one  cravat  in  the  manner  first  pointed  out  above ;  and 
then  placing  the  centre  of  a  second  in  the  other  axilla,  its 
tails  being  conducted  obliquely  upwards,  one  before  and  the 
other  behind  the  chest,  to  be  attached  to  the  tails  of  the  first 
at  their  point  of  junction. 

USE. — To  retain  dressings  in  both  axillse  at  once. 
i     3.   The  crossed  bandage  of  the  shoulder  and  axilla. 

COMPOSITION. — A  roller  eight  yards  long  and  two  inches 
wide. 

APPLICATION. — Confine  the  initial  extremity  of  the  roller 
to  the  arm  of  the  affected  side,  by  a  few  circular  turns  pass- 
ing from  before  backwards  and  from  without  inwards.  Then 
carry  the  roller  obliquely  upwards  over  the  shoulder  of  the 
same  side,  and  downwards  obliquely  over  the  front  of  the 
chest  to  the  opposite  axilla.  From  this  point,  the  roller 
should  cross  the  back  obliquely  upwards  to  the  shoulder  of 
the  affected  side,  and,  traversing  the  descending  turn,  regain 
the  arm  from  which  it  started.  Several  crosses  may  be  made 
in  the  same  manner,  and  the  roller  terminated  by  circular 
sweeps  around  the  arm. 

USE. — To  confine  applications  made  to  the  shoulder,  or  to 
the  axilla, — or  to  exercise  pressure  upon  these  parts,  which 
may  be  aided  by  the  employment  of  compresses. 


100     BANDAGES  FOR  THE   UPPER   EXTREMITIES. 

4.  For  the  crossed  bandage  of  both  shoulders  and  axillae, 
see  Section  II. 

5.  A  sling  for  the  fore-arm. 

Place  the  middle  of  a  triangle  beneath  the  fore-arm,  with 
the  apex  towards  the  elbow;  then  carry  the  extremities 
obliquely  upwards,  the  anterior  over  the  shoulder  of  the 
sound  side,  and  the  posterior  over  that  of  the  aifected  side, 
and  tie  them  around  the  neck. 

To  suspend  the  hand  and  wrist,  an  oblong  piece  of  linen, 
or  muslin,  or  a  cravat,  may  be  employed,  and  the  part  placed 
upon  its  centre  ;  then  tie  the  lateral  portions  together,  leaving 
the  hand  loosely  confined,  and  suspend  the  whole  to  some 
convenient  part  of  the  patient's  dress,  or  to  the  neck. 

6.  The  carpo-digito-dorsal  triangle,  of  Mayor. 
APPLICATION. — Place  the  triangle  upon  the  back  of  the 

hand,  its  base  being  upon  the  wrist,  around  which  the  tails 
are  to  be  wrapped  and  confined;  then,  having  flexed  the 
fingers  to  the  proper  degree,  draw  the  apex  of  the  triangle 
over  them  and  attach  it  to  the  envelope  of  the  wrist. 

USE. — To  approximate  the  edges  of  wounds  in  the  palm 
of  the  hand,  or  on  the  palmar  surface  of  the  fingers  ;  also  to 
prevent  the  deformities  which  are  likely  to  occur  from  the 
cicatrization  of  burns  on  the  dorsal  aspect  of  the  hand. 

7.  The  palmo-digito-brachial  triangle. 

APPLICATION. — Tie  a  band  around  the  arm,  just  above  the 
condyles  of  the  humerus ;  then  place  a  triangle  upon  the 
palmar  surface  of  the  hand,  its  base  overlaying  the  wrist, 
around  which  the  tails  are  wrapped  and  confined, — and  reflect 
the  apex  over  the  fingers  and  back  of  the  hand,  to  be  attached 
to  the  extremity  of  the  supra-condyloid  band. 

USE.  —  In  transverse  wounds  of  the  dorsal  aspect  of  the 
hand  and  fingers,  and  in  burns  of  their  palmar  face. 

8.  The  spiral  bandage  of  the  upper  extremity  is  effected 
by  the  use  of  a  roller,  eight  yards  long  and  two  and  a  half 
inches  wide  :  compresses  if  required. 

APPLICATION.  —  Confine  the  initial  extremity  of  the  roller 
upon  the  wrist  by  circular  turns  passing  from  the  radial  to- 
wards the  ulnar  side,  —  the  hand  being  supine;  traverse  the 
palm  and  the  back  of  the  hand  obliquely  to  gain  the  ends  of 
the  fingers,  and  then  return  to  the  fraenum  of  the  thumb  by 
simple  spiral  turns :  envelope  the  ball  of  the  thumb  and  the 


BANDAGES  FOR  THE  UPPER  EXTREMITIES.   101 


wrist  by  folds  in  the  form  of  a  figure  8,  and  ascend  the 
fore-arm  by  spiral  and  reversed  sweeps  around  the  part. 
Having  reached  the  elbow,  place  the  arm  in  the  proper  posi- 
tion;  if  straight,  continue  the  spiral  and  reversed  turns  to 
the  shoulder :  if  flexed,  cover  the  elbow  with  crossed  folds  in 
the  form  of  the  figure  8,  and  then  ascend  as  before. 

USE.  —  To  envelope  the  arm,  and  to  make  uniform,  or 
graduated,  compression  upon  it.  Great  care  is  necessary, 
especially  in  case  of  injury,  to  avoid  exercising  too  much 
pressure  upon  the  member,  as  serious  inconveniences  and 
accidents  have  resulted  from  inattention  in  this  respect. 

9.  The  spica  bandage  of  the  upper  part  of  the  arm  and 
the  shoulder. 

•  COMPOSITION.  —  A  roller,  eight  yards  long  and  two  and  a 
half  inches  wide,  with  compresses  for  the  axilla  of  the  affected 
side. 

APPLICATION. — The  right  arm  being  the  one  which  requires 
the  bandage,  place  the  roller  upon  the  upper  part  of  the  arm, 
so  that  about  two  feet  of 
its  free  portion  shall  de- 
pend from  the  outer  side 
of  the  member ;  confine  it 
in  this  position  by  one  or 
two  spiral  and  reversed 
turns,  passing  around  the 
limb  from  its  outer  towards 
its  inner  face ;  then  carry 
the  roller  up  over  the  outer 
aspect  of  the  shoulder,  to 
descend  obliquely  across 


FIG.  37. 


the  chest,  in  front,  to  the 
axilla  of  the  sound  side, 
and  return  to  the  affected 
shoulder  along  the  back  of 
the  chest :  descend  into  the 
axilla  along  the  front  of 
the  shoulder,  and  then 
mount  over  its  posterior 
face  to  traverse  the  front 
of  the  chest,  as  before ; 

having  thus  laid  several  folds,  secure  the  terminal  end  of  the 
9  * 


102      BANDAGES   FOR    THEUPPER   EXTREMITIES. 

roller  by  a  pin  ;  now  bring  the  initial  portion  of  the  bandage., 
which  was  left  depending  from  the  posterior  face  of  the  arm, 
to  the  front,  over  the  anterior  fold  of  the  axilla  and  the 
shoulder,  and  around  the  back  of  the  neck,  to  terminate  in 
front  of  the  chest,  on  the  sound  side,  (fig.  37.) 

USE.  —  To  exercise  compressing  force  around  the  upper 
part  of  the  arm  and  shoulder. 

10.  The  spica  bandage  of  the  thumb. 

COMPOSITION.  —  A  roller  three  yards  long  and  one  inch 
wide. 

APPLICATION.  —  Confine  the  initial  extremity  to  the  wrist 
by  circular  turns  passing  from  the  radial  to  the  ulnar  margin, 
the  hand  being  held  in  a  vertical  position  with  the  thumb 
above ;  now  carry  the  roller  from  the  palmar  towards  the 
dorsal  aspect  of  the  thumb,  between  it  and  the  index  finger, 
sweep  around  the  base  of  the  former  and  the  wrist  to  regain 
the  palmar  surface  of  the  thumb ;  repeat  this  process  until 
the  roller  is  exhausted,  and  then  confine  its  terminal  end. 

USE. — To  compress  the  thumb  and  to  restrain  its  motions, 
as  after  dislocation. 

A  spica  bandage  may  be  applied  around  any  of  the  fingers, 
after  the  same  manner. 

11.  The  gauntlet. 

COMPOSITION. — A  roller  eight  yards  long  and  an  inch  wide. 

APPLICATION.  —  Confine  the  initial  extremity  to  the  wrist 
by  a  few  circular  turns,  then  descend  to  the  tip  of  each 
finger,  successively,  by  oblique  sweeps  of  the  roller,  returning 
in  spiral  and  reversed  turns  to  the  metacarpo-phalangeal  ar- 
ticulation :  terminate  the  bandage  by  circulars  around  the 
body  of  the  hand  and  the  wrist.  (Fig.  38.) 

USE. — To  prevent  the  opposed  surfaces  of  the  fingers  from, 
uniting  in  the  cicatrization  of  burns ;  to  make  general  com- 
pression upon  the  hand,  and  to  assist  in  the  cure  of  fractures 
and  dislocations  of  its  bone 

12.  The  demi-gauntlet. 

COMPOSITION. — A  roller  five  yards  long  and  one  inch  wide. 

APPLICATION.  —  The  hand  being  prone,  confine  the  initial 
extremity  of  the  bandage  about  the  wrist  by  circular  turns 
passing  from  its  ulnar  to  its  radial  side ;  then  discontinuing 
the  circular  at  the  cubital  side,  carry  the  roller  obliquely 
across  the  back  of  the  hand  to  the  radial  margin  of  the 


BANDAGES  FOR  THE  UPPER  EXTREMITIES.   103 


index  finger  at  the  junction  of  the  phalanx  with  the  meta- 
carpus, across  the  palmar  face  to  the  cubital  margin,  and 
thence  around  to  the  radial  border  of  the  hand;  cross  the 


FIG.  38. 


FIG.  39. 


palm  to  its  cubital  side,  over  the  back  of  the  hand  to  the 
index  side  of  the  middle  finger,  around  the  base  of  this  to  its 
cubital  aspect  and  then  to  the  radial  border  of  the  hand ;  so 
continuing  until  the  root  of  each  finger  is  covered  ;  terminate 
the  bandage  by  a  circular  sweep  around  the  wrist.  (Fig.  39.) 
USE. — A  light  retaining  bandage  for  the  back  of  the  hand. 

13.  The  triangle  cap  for  the  hand. 

APPLICATION.  —  Lay  the  hand  upon  the  triangle,  the  base 
overlapping  the  wrist ;  reflect  the  apex  over  the  extremities 
of  the  fingers  upon  the  wrist,  and  secure  it  in  this  position 
by  wrapping  the  tails  of  the  triangle  around  the  same  part. 

USE. — To  retain  applications  upon  the  hand,  which  it 
effects  very  perfectly  and  readily. 

14.  The  cravat  bandage  for  the  palm  or  back  of  the  hand. 
APPLICATION. — Place  the  palm,  or  the  back  of  the  hand, 

upon  the   centre  of  the  cravat;  reflect  the  tails  upon  the 


104   BANDAGES  FOR  THE  LOWER  EXTREMITY. 

other  surface,  and  cross  them;  after  which,  tie  them  about 
the  wrist. 

USE. — An  effectual  and  convenient  retaining  bandage  for 
the  body  of  the  hand. 

15.  The  perforated  bandage  of  the  hand  is  made  of  a 
piece  of  muslin  or  linen  large  enough  to  envelope  the  hand, 
having  attached  to  its  lower  margin  a  band  half  a  yard  or 
more  in  length,  and  an  inch  wide,  and  being  perforated 
near  its  superior  border  by  holes  corresponding  with  the 
fingers. 

APPLICATION. — Insert  the  fingers  through  their  respective 
fenestrge,  and  draw  the  piece  over  the  hand,  enveloping  the 
latter  neatly  and  accurately ;  secure  it  thus  by  the  band. 

USE. — Same  as  of  the  preceding. 

SECTION  IV. 
BANDAGES  FOR  THE  LOWER  EXTREMITY. 

1.  The  cruro-iliac  triangle,  of  Mayor. 
COMPOSITION. — A  cravat,  and  a  triangle. 
APPLICATION. — Knot  the  cravat  around  the  pelvis,  passing 

it  just  below  the  crsst  of  the  ilium ;  place  the  centre  of  the 
base  of  the  triangle  immediately  beneath  the  great  trochariter, 
encompass  the  thigh  with  the  tails  of  the  bandage,  and  tie 
their  extremities,  or  confine  them  with  pins ;  then  raise  the 
apex  of  the  triangle,  and  inserting  it  between  the  surface  of 
the  body  and  the  cravat  which  girdles  the  pelvis,  reflect  it 
back  upon  the  body  of  the  triangle  and  pin  it. 

USE. — To  confine  applications  made  upon  the  gluteal 
region. 

2.  The  bandage  of  Scultetus  is  described  fully  in  Sect.  II. 
Chap.  I. 

3.  The  eighteen-tailed  bandage  for  the  lower  extremity. 
COMPOSITION. — Stitch  transversely  to  a  band  of  muslin,  of 

sufficient  length,  and  about  four  inches  wide,  eighteen  other 
strips,  three   or  four  inches  in  width,  and  long  enough  to] 
make  one  circuit  and  a  half  about  the  limb  ;  —  the  centre  of  j[ 
each  transverse  band  crossing  the  vertical,  and  the  individual 
pieces  arranged  in  the  same  manner  as  the  strips  of  the  ban- 
dage of  Scultetus,  which  it  resembles  in  its  application  and 
uses ;  as  before  stated,  it  has  the  disadvantage  of  requiring 


BANDAGES   FOR   THE   LOWER   EXTREMITY.       105 

the  removal  of  the  whole,  if  a  single  portion  of  the  bandage 
become  deranged  or  unfit  for  longer  employment;  hence  it 
is  but  little  used,  the  other  being  preferred. 

4.  Invaginated  bandages  for  longitudinal  and  transverse 
wounds  of  the  thigh.      For  a  description  of  the  composi- 
tion of  these,  consult  Sect.  II.  Chap.  I.     Their  application 
will  be  illustrated  in  the  chapter  on  wounds. 

5.  The  crossed  bandage  of  the  knee. 

COMPOSITION. — A  roller  four  yards  long  and  two  and  a 
half  inches  wide. 

APPLICATION. — Confine  the  initial  extremity  upon  the 
thigh,  just  above  the  knee,  by  circular  turns  sweeping  around 
the  limb  from  left  to  right  (of  the  dresser) ;  then  conduct  the 
roller  obliquely  across  the  top  of  the  knee  to  the  posterior 
aspect  of  the  leg,  around  which  a  circular  turn  is  effected, 
and  the  roller  made  to  ascend  diagonally  over  the  knee, 
crossing  the  first  oblique:  having  reached  the  lower  part  of 
the  thigh,  a  circular  turn  is  made,  after  which  the  oblique 
and  circular  folds  alternate  with  each  other  in  the  manner 
described,  and  the  bandage  terminates  in  a  circular  turn  below 
or  above  the  knee. 

USE. — To  exercise  compression  upon  the  knee,  or  to  retain 
dressings  in  this  situation.  The  same  object  may  be  attained 
in  the  popliteal  region,  by  crossing  the  bandage  behind, 
instead  of  in  front. 

It  will  readily  be  seen  that  a  triangle,  or  a  cravat,  will 
fulfil  the  same  purpose ;  the  former  as  a  retaining,  the  latter 
as  a  compressing  bandage,  when  only  a  moderate  degree  of 
force  is  called  for. 

6.  Weiss's  elastic  knee-cap,  made  of  some  elastic  web,  and 
lined  with  India-rubber  cloth,  or  having  strips  of  India  rubber 
inserted  between  its  layers,  gives  a  very  agreeable  and  suffi- 
ciently compressive  support  to  the  knee :  it  is  confined  about 
the  joint  by  lacing. 

As  a  substitute  for  this,  the  elastic  bandage  made  of  wool- 
len yarn  knit,  —  described  with  the  laced  bandage,  in  the 
second  section  of  the  first  chapter, — may  be  employed. 

7.  The  spiral  bandage  of  the  lower  extremity. 
COMPOSITION. — A  roller  six  yards  long  and  two  and  a  half 

i  iches  wide. 

APPLICATION. — This  may  be  accomplished  in  several  ways- 


106      BANDAGES    FOR    THE    LOWER    EXTREMITY. 


1st.  Confine  the  initial  extremity  of  the  roller  around  the 
ankle,  say  of  the  right  leg,  by  circular  turns  revolving  from- 
its  outer  to  its  inner  side :  having  reached,  in  the  second  cir- 
cular turn,  the  external  malleolus,  conduct  the  roller  across 
the  instep  obliquely  to  the  inner  side  of  the  foot,  and  beneath 
the  sole  to  the  little  toe ;  then  retrace  the  course,  covering 
the  foot  with  two  or  more  spiral  turns ;  having  regained  the 
instep,  ascend  it  obliquely  and  sweep  around  the  leg  from  the 
inner  to  the  outer  side ;  thence  cross  obliquely  to  the  inner 
margin  of  the  instep,  wind  beneath  the  sole  and  the  outer  side 
of  the  foot,  in  advance  of  the  malleolus,  mount  over  the  instep 
to  the  tibial  side  of  the  leg,  and  then  conduct  the  roller  to  the 
knee  in  spiral  and  reversed  turns.  If  the  limb  be  straight, 
continue  the  same  with  a  fresh  roller,  if  necessary,  until  the 
whole  limb  shall  be  covered.  If,  however,  the  knee  be  flexed, 
the  joint  must  be  enveloped  with  folds  in  the  form  of  the  figure 
8,  and  circular  if  need  be;  then  ascend  the  thigh  as  in  the 
other  case  (fig.  16,  d). 

This  mode  of  bandaging  the  limb  is  very  simple  and  secure ; 
the  only  objection  to  it  is  that  it  leaves  the  heel  uncovered ; 
and  as  this  part  sometimes  swells  and  becomes  painful  if  left 
exposed  while  the  parts  above  are  protected,  it  behooves  the 
dresser  to  avoid  this  difficulty,  as  in  the  following  mode : 
2d.  The  right  leg  being  selected,  confine  the  initial  extre- 
mity of  the  roller  as  above  ;  then, 
instead  of  crossing  the  instep, 
wind  around  the  inner  malleolus, 
and  over  the  ridge  of  the  tendo 
Achillisjust  above  its  attachment 
to  the  heel,  over  the  space  between 
the  external  malleolus  and  the  ex- 
tremity of  the  heel,  and  then  cross 
the  sole  of  the  foot  by  a  single 
oblique  sweep,  to  the  great  toe ; 
cover  the  foot  from  the  toes  to 
the  instep  by  spiral  turns,  and 
then  wind  around  the  inner  side 
of  the  heel,  crossing  the  space 
between  the  inner  malleolus  and 
the  point  of  the  calcaneum,  over 
the  arch  of  the  tendo  Achillis  to  the  outer  side  of  the  leg,  just 


FIG.  40. 


BANDAGES  FOB  THE  LOWER  EXTREMITY.   107 

above  the  malleolus  ;  now  pass  over  the  instep  and  the  point 
of  the  heel  to  the  instep  again,  and  wind  the  roller  in  the 
form  of  the  figure  8,  around  the  leg,  the  instep,  and  the  sole, 
when,  having  conducted  the  bandage  to  the  tibial  margin 
of  the  leg,  ascend  the  limb  by  spiral  and  reversed  turns 
(fig.  40). 

3d.  The  French  spiral,  as  it  is  termed,  differs  but  little 
from  the  first.  It  is  usually  commenced  by  merely  placing 
the  initial  extremity  upon  the  outer  margin  of  the  instep 
(but  this  is  less  secure  than  if  it  is  confined  around  the  ankle) ; 
now  wind  obliquely  around  the  foot  to  the  great  toe,  arid 
beneath  the  sole  to  the  opposite  side ;  from  this  point  cover 
the  foot  with  spiral  and  reversed  turns,  extending  as  high  up 
on  the  instep  as  may  be  consistent  with  the  firmness  of  the 
bandage,  and  ascend  the  leg  at  once,  in  spiral  and  reversed 
sweeps,  without  enveloping  the  heel. 

USE. — To  restrain  the  action  of  the  muscles  of  the  leg ;  to 
compress  the  limb  uniformly,  and  to  assist  in  procuring  the 
removal  of  indolent  swelling  of  the  soft  parts,  whether  caused 
by  serous  infiltration,  chronic  inflammation,  or  otherwise. 

8.  Baynton's  bandage  for  the  treatment  of  ulcers. 

This  mode  of  treatment  has  been  already  described  in  the 
first  part  of  the  book,  in  the  course  of  the  remarks  on  Adhe- 
sive Plaster.  For  an  illustration  of  its  application,  see  fig.  40. 

9.  The  laced  stocking  is  made  of  buckskin,  or  of  some  elas- 
tic web.     It  is  formed  of  two  pieces  fitted  to  the  shape  of  the 
limb  and  sewed  together  along  the  back  of  the  leg  and  the  sole 
of  the  foot :  the  anterior  margins  are  provided  with  eyelet 
holes,  for  the  purpose  of  lacing  the  stocking  when  applied ; 
and  in  order  to  obviate  the  inconveniences  which  might  arise 
from  the  direct  contact  of  the  lacing  apparatus  with  the  skin, 
a  piece  of  some  soft  material  should  be  sewed  along  the  inner 
surface  of  one  of  these  anterior  borders. 

USE. — To  exert  a  uniform  and  equable  pressure  around  the 
leg,  particularly  in  case  of  varicose  veins. 

10.  An  elastic  gaiter  for  the  foot  and  ankle  may  be  very 
well  made  of  India-rubber  cloth,  lined  with  linen  or  silk,  so 
contrived  as  to  correspond  with  the  shape  of  the  part,  and 
still  be  elastic :  it  should  be  confined  upon  the  foot  by  lacing 
along  the  outer  side. 

USE. — To  support  the  foot  and  ankle  after  sprains  of  the 
part,  or  in  chronic  intumescence  from  any  cause. 


PART    III. 

BANDAGES  AND  APPARATUS  EMPLOYED  IN  THE  TREAT- 
MENT OF  FRACTURES. 

CHAPTER  I. 

GENERAL  CONSIDERATIONS  ON  THE  TREATMENT  OF  FRACTURES. 

THE  method  by  which  nature  effects  the  cure  of  a  fracture 
is,  the  formation  of  -what  is  technically  called  "  The  Callus ;" 
the  different  steps  of  this  process  are  thus  briefly  stated  by 
Miiller,  (Physiol.,  vol.  i.  p.  454): — "The  inflammation  which 
ensues  immediately  after  the  fracture  of  a  bone  affects  princi- 
pally the  surrounding  soft  parts,  viz.,  the  periosteum,  cellular 
tissue,  and  muscles,  which  all  become  enlarged  and  aggluti- 
nated together,  so  as  to  form  a  firm  capsule  around  the  frac- 
ture.. On  the  inner  surface  of  this  capsule  there  is  formed,  as 
a  result  of  the  inflammation,  a  semi-fluid  substance  which  gra- 
dually acquires  more  consistence  and  becomes  traversed  by 
vessels.  A  similar  substance  is  effused  by  the  medullary  tis- 
sue of  the  broken  bone;  and  this,  together  with  the  substance 
poured  out  by  the  capsule,  at  length  coalesces,  and  forms  the 
mass  enclosed  in  the  capsule  and  investing  the  ends  of  the 
bone,  to  which  the  name  of  'substantia  intermedia'  has  been 
given.  This  substance  acquires  a  fibrous  texture,  and  fills  all 
the  space  between  the  bones ;  while  the  muscles,  cellular  tis- 
sue, and  periosteum  return  to  their  former  normal  condition. 
The  inflammation  does  not  affect  the  bone  so  soon  as  it  does 
the  soft  parts ;  it  commences  in  it  at  some  little  distance  from 
the  fractured  extremities,  namely,  at  the  part  where  the  bone 
is  still  invested  with  periosteum,  and  at  the  corresponding 
point  in  the  interior.  The  bone  likewise  now  pours  out  a  ge- 
latinous exudation,  in  which  vessels  become  developed,  and 

(108) 


TREATMENT  OF  FRACTURES.        109 

which  continues  to  grow :  while,  on  the  side  by  which  it  is  con- 
nected with  the  bone,  it  becomes  converted  into  cartilage  and 
bone.  This  new  mass — the  proper  callus, — also  occupies  to 
a  greater  or  less  extent  the  medullary  cavity.  On  the  exte- 
rior, its  formation  is  continued  towards  the  fractured  extremi- 
ties, till  the  exudations  of  the  two  portions  of  bone  meet  and 
unite.  Thus  is  formed  the  primitive  callus. 

"  In  the  meantime,  the  surface  of  the  bone  unites  with  the 
capsule  formed  by  the  soft  parts  and  the  primitive  callus,  and 
the  margins  of  the  fracture  unite  with  the  l  substantia  inter- 
media.' Callus,  too,  is  formed,  and  developes  itself  at  the  ex- 
pense of  the  now  ligamentous  '  substantia  intermedia.'  Peri- 
osteum is  formed  anew  on  the  external  uneven  surface  of  the 
callus. 

"  The  further  changes  which  the  callus  undergoes  after  the 
ends  of  the  bone  have  united,  consist  in  the  restoration  of  the 
medullary  cavity  in  its  substance,  and  in  the  change  of  its 
form.  The  texture  of  the  callus  undergoes  the  same  changes 
as  the  cartilage  of  bone  in  ossification.  While  it  is  cartilagi- 
nous, it  contains  the  peculiar  corpuscles  of  cartilage ;  when  it 
ossifies,  it  assumes  the  cellular  texture  of  bone." 

According  to  Dupuytren,  the  period  during  which  the  pro- 
visional callus  is  being  formed,  continues  until  the  thirtieth  or 
fortieth  day.  In  the  subsequent  period,  the  ossification  of  the 
cartilaginous  intersubstance — "  substantia  intermedia" — takes 
place  not  before  the  fourth  or  sixth  month  ;  the  swelling  of  the 
soft  parts  having  been  first  removed  by  absorption,  the  bony 
mass  filling  up  the  medullary  canal  is  likewise  absorbed,  and 
this  cavity  restored  at  the  end  of  six  to  twelve  months. 

According  to  the  observations  of  Mr.  Paget,  the  provisional 
callus  rarely  exists  in  the  human  subject,  excepting  in  the 
case  of  those  bones  which  cannot  be  kept  at  rest,  as  the  ribs  ; 
while  it  is  of  common  occurrence  in  the  inferior  animals. 
(Paget's  Lectures  on  Surgical  Pathology,  vol.  1.) 

Now,  the  aim  of  the  surgeon,  in  the  treatment  of  fractures, 
should  be  to  place  and  preserve  the  injured  parts  in  such  cir- 
cumstances as  shall  most  conduce  to  the  accomplishment  of 
the  reparative  processes  just  mentioned.  To  effect  this,  three 
steps  are  necessary : 

1st.  To  secure  the  proper  apposition  of  the  fragments,  if, 


110        TREATMENT  OF  FRACTURES. 

as  is  generally  the  case,  the  broken  ends  have  suffered 
displacement ; 

2d.  To  retain  the  fragments  in  this  position ; 

3d.  To  prevent  or  remedy  any  unpleasant  symptoms  attend- 
ing or  following  the  fracture. 

The  method  by  which  these  indications  may  be  best  ful- 
filled claims  a  brief  consideration. 

1.  The  reduction  of  the  fracture  is  effected  by  extension 
and  counter-extension,  the  first  acting  upon  the  inferior  or 
distal  fragment,  the  last  on  the  superior  or  proximal. 

There  is  some  diversity  of  opinion  respecting  the  point 
from  which  the  fragments  should  be  operated  upon :  sur- 
geons of  the  French  school  applying  the  extending  force  to 
that  portion  of  the  limb  which  articulates  with  the  inferior 
fragment,  and  the  counter-extension  to  that  with  which  the 
superior  is  connected ;  while  the  English  make  the  extending 
force  upon  the  lower  fragment  itself,  and  the  counter-extend- 
ing upon  the  upper. 

To  each  of  these  plans  there  are  objections  and  disad- 
vantages attached,  if  exclusively  insisted  upon.  The  argu- 
ment urged  by  the  Continental  surgeons  against  the  latter, 
viz.,  that  by  grasping  the  muscles  which  are  connected  with 
the  fragments  themselves,  the  reduction  is  rendered  more 
difficult  and  more  painful,  because  the  muscles  are  made  to 
counteract  more  vigorously  the  reducing  forces, — is  not  really 
of  much  weight.  For  the  efforts  made  to  reduce  a  fracture 
need  never  be  violent ;  the  force  operates  gradually,  and  is 
exerted  mediately  or  immediately  by  the  hands ;  and,  more- 
over, the  muscular  contraction  with  which  the  surgeon  has  to 
contend  is  induced,  probably,  by  the  irritation  inflicted  upon 
the  muscular  fibres  as  the  irregular  and  sharp  extremities  of 
the  fractured  bone  glide  over  them,  during  the  action  of  the 
extending  and  counter-extending  forces,  rather  than  by  the 
mere  grasping  of  the  muscles  by  the  hands  ;  and  it  will,  there- 
fore, be  excited,  whether  the  forces  act  upon  the  broken  bone, 
or  upon  portions  of  the  limb  more  distant  from  the  seat  of 
injury.  If  the  French  mode  of  reduction  be  practised,  the 
surgeon  is  obliged  to  overcome  the  contractile  force,  not  only 
of  the  muscles  directly  connected  with  the  broken  bone,  but 
of  those  likewise  which  have  their  attachments  to  the  more 
distant  parts  through  which  he  operates. 


TREATMENT  OF  FRACTURES.        Ill 

In  reducing  a  fracture,  the  surgeon  may,  therefore,  consult 
his  convenience  as  to  which  mode  he  shall  adopt ;  if  the  thigh 
has  been  broken,  it  will  be  most  conveniently  reduced  by 
acting  upon  the  pelvis,  and  the  ankle  and  leg  just  above  the 
ankle ;  if  the  fore-arm  is  the  seat  of  fracture,  the  injury  may 
most  easily  be  remedied,  and  with  least  assistance  of  attend- 
ants, by  placing  this  member  upon  a  proper  splint,  and  ope- 
rating upon  the  elbow  and  wrist,  the  surgeon  himself  making 
both  extension  and  counter-extension,  while  the  splint,  with 
the  fore-arm  resting  upon  it,  is  supported  by  his  knee,  or  by 
an  attendant. 

The  amount  of  force  employed  in  the  reduction  must  be 
adapted,  of  course,  to  the  resistance  to  be  overcome ;  it 
should  be  gradually  and  steadily  exerted.  Much  assistance 
will  be  derived  from  so  arranging  the  position  of  the  limb  as 
that  the  most  powerful  muscles  —  those  whose  contraction  is 
most  opposed  to  the  proper  restoration  of  the  fragments, — 
shall  be  shortened,  and  thus, rendered  in  a  measure  quiescent : 
i.  e.,  the  limb  should  be  more  or  less  flexed ;  and  after  the 
reduction  of  the  fracture  has  been  effected,  this  flexed  posi- 
tion may  be  maintained,  or  the  limb  may  be  slowly  and 
cautiously  straightened,  as  the  'views  of  the  surgeon,  with 
regard  to  the  permanent  position  of  the  limb  during  the  treat- 
ment, shall  dictate.  The  irritability  of  the  muscles  may  be 
lessened  by  the  administration  of  opium,  and  by  distracting 
the  patient's  attention  from  his  injury,  while  the  reduction  is 
being  effected. 

The  extending  force  should  be  made  in  the  direction  which 
the  limb  has  assumed  since  the  fracture:  and  then,  as  the 
proper  line  is  gradually  regained,  the  traction  should  coincide 
with-it.  • 

As  soon  as  the  natural  length  of  the  limb  has  been  re 
stored,  the  surgeon  should  adjust  the  fragments  as  accurately 
as  possible.  To  this  step  the  term  "coaptation  "  is  commonly 
applied.  It  is  accomplished  by  pressing  gently  all  around 
the  neighbourhood  of  the  seat  of  fracture,  avoiding,  as  far  as 
may  be  practicable,  all  pressure  directly  over  and  upon  the 
fragments,  in  order  not  to  give  pain,  and  that  the  soft  parts 
immediately  in  contact  with  the  splintered  ends  of  the  bone 
shall  not  be  wounded  and  irritated,  more  than  may  be  un- 
avoidable. The  points  of  the  fingers  should  not  be  used, 


112  TREATMENT    OF    FRACTURES. 

therefore,  but  the  hand  should  be  laid  flatly  upon  the  part, 
and  very  gentle  pressure  be  gradually  made  from  side  to  side. 

2.  The  fracture  having  been  thus  reduced,  the  aim  of  the 
surgeon  is  to  maintain  the  fragments  in  apposition,  until  con- 
solidation shall  have  become  perfected,  or,  in  other  words,  to 
preserve  these  parts  in  a  state  of  perfect  rest.  This  can  be 
accomplished  only  by  mechanical  appliances  which  shall  pre- 
vent displacement  of  the  fragments  arising  either  from  simple 
muscular  contractions,  or  from  external  causes,  or  both. 
There  are  some  exceptional  cases  from  time  to  time  occurring, 
in  which, — from,  the  fracture  being  perfectly  transverse,  and 
unattended  by  displacement  of  the  fragments, — it  may  not 
be  absolutely  necessary  to  confine  the  injured  part;  but  even 
in  such  cases,  no  prudent  surgeon  would  neglect  to  do  so,  in 
order  to  guard  against  accident  or  violence. 

The  mechanical  means  of  retention  employed  in  the  treat- 
ment of  fractures  consist,  of  bandages,  compresses  of  various 
forms  and  sizes,  and  splints.  These  will  be  more  particularly 
enumerated  and  described,  when  special  fractures  are  treated 
of. 

The  operation  of  these  means  of  reduction  and  retention 
will  be  much  aided  by  a  proper  position  of  the  limb  which  is 
the  seat  of  the  fracture,  —  that  position,  namely,  which  will 
relax  the  most  powerful  muscles,  connected  with  either  frag- 
ment. The  question  of  position  will  be  more  particularly 
referred  to  in  the  section  on  the  treatment  of  fractures  of  the 
thigh,  to  which  it  has  more  especial  reference. 

There  are  some  exclusive  plans  of  treating  fractures  which 
merit  description  :  these  are  chiefly, — 1st.  The  treatment  by 
the  "immovable  apparatus;"  and  2d.  The  hyponarthecic 
method  of  Sauter  and  Mayor.  . 

The  first — or  the  method  of  treatment  by  the  "immovable 
apparatus,"  —  seems  to  have  been  introduced  into  France 
from  Spain,  under  the  auspices  of  the  celebrated  Baron 
Larrey.  As  employed  by  this  surgeon,  the  mode  of  its  appli- 
cation was  to  surround  the  limb  —  the  fracture  having  been 
reduced,  and  the  limb  placed  in  the  straight  position, — by 
compresses,  of  suitable  form  and  dimensions,  saturated  with  a 
mixture  of  white  of  egg,  comphorated  alcohol  and  subacetate 
of  lead,  and  retained  upon  the  limb  by  folds  of  the  bandage 
of  Scultetus,  likewise  saturated  with  the  same  mixture ;  the 


TREATMENT  OF  FRACTURES.        113 

member  was  kept  completely  quiescent  until  the  bandage  had 
become  perfectly  stiff  and  firm,  forming  a  rigid  case  around 
the  limb.  (Vidal  de  Cassis,  Trait,  de  Pathol.  Ext.  vol.  ii. 
237,  &c.) 

Since  the  time  of  Larrey,  several  modifications  of  this 
method  of  treatment  have  been  originated,  and  adopted  in 
practice. 

M.  Seutin,  of  Belgium,  employs  the  following  apparatus : 
it  consists  of  strips  of  muslin  arranged  as  in  the  bandage  of 
Scultetus ;  compresses  of  old  linen,  or  of  lint,  and  pieces  of 
pasteboard  softened  in  boiling  water  so  as  to  be  moulded  to 
the  limb.  In  applying  this  dressing,  the  fracture  is  reduced, 
the  limb  restored,  as  nearly  as  possible,  to  its  natural  shape, 
and  then  covered  with  folds  of  the  bandage  of  Scultetus,  or 
of  the  simple  roller ;  upon  this  a  layer  of  freshly  prepared 
starch  is  applied  by  the  hand,  or  by  means  of  a  brush ;  then, 
having  filled  up  the  irregularities  upon  the  surface  with  suit- 
able compresses,  the  whole  is  enveloped  in  several  layers  of 
the  bandage  of  Scultetus,  or  of  the  roller,  thoroughly  im- 
pregnated with  the  paste ;  for  the  sake  of  cleanliness  the  last 
envelope  should  be  applied  dry. 

If  there  be  a  wound  of  the  integuments,  or  if  the  fracture 
be  compound,  M.  Seutin  directs  that  an  aperture,  correspond- 
ing in  situation  with  the  wound,  should  be  made  in  the  band- 
age, or  that  the  various  dressings  should  not  be  applied  upon 
this  point. 

During  the  thirty-six  or  forty-eight  hours  required  for  the 
hardening  of  this  case,  the  limb  should  be  retained  motionless 
in  some  secure  apparatus. 

At  the  expiration  of  from  two  to  four  days,  M.  Seutin 
directs  that  a  slit  should  be  made  running  longitudinally 
through  the  entire  thickness  of  the  envelope,  so  as  to  permit 
of  the  inspection  of  the  limb  ;  if  its  condition  be  favourable, 
the  case  is  closed  again  by  applying  an  additional  layer  or 
two  of  the  starched  bandage ;  if  the  parts  be  too  much  com- 
pressed, throughout,  a  longitudinal  section  is  made  and  a 
strip  removed ;  or  if  there  be  too  much  pressure  upon  any 
point  merely,  only  portions  of  the  case  are  cut  away  at  cor- 
responding points  ;  after  which  the  apparatus  is  again  secured 
as  before.  In  this  wav,  during  the  whole  duration  of  the 


114        TREATMENT  OF  FRACTURES. 

treatment,  the  limb  should  be  inspected  from  time  to  time, 
and  any  difficulty  remedied. 

As  soon  as  the  dressing  has  become  perfectly  solid,  M. 
Seutin  allows  the  patient — the  lower  extremity  being  the  seat 
of  fracture  —  to  walk  about  upon  crutches,  the  broken  limb 
supported  from  contact  with  the  ground  by  a  sling  attaching 
it  to  the  neck. 

M.  Velpeau  advocates  a  plan  somewhat  different  from  M. 
Seutin's.  The  solidifying  material  which  he  employs  consists 
of  one  hundred  parts  of  dextrine  beaten  up  with  sixty  parts 
of  comphorated  alcohol,  to  which  is  added  forty  parts  of  hot 
water,  and  the  mixture  is  then  shaken ;  in  two  minutes  the 
solution  is  ready  for  use.  Having  reduced  the  fracture,  M. 
Velpeau  applies  a  dry  roller  around  the  limb,  and,  after  filling 
up  the  inequalities  of  the  surface  by  compresses,  follows  it  by 
a  roller  saturated  with  the  above  solution  ;  sometimes  he  uses 
also  pasteboard  splints  properly  softened  and  moulded  to  the 
limb,  or,  if  these  be  not  employed,  he  applies  in  succession  a 
sufficient  number  of  bandages,  previously  saturated,  to  afford 
firm  support  and  protection.  The  limb  is  kept  at  rest  until 
the  dextrine  shall  have  become  dry. 

M.  Velpeau  makes  use  of  this  dressing  immediately  after 
the  occurrence  of  the  injury,  notwithstanding  the  existence 
of  swelling  and  inflammation,  considering  that  the  compres- 
sion which  the  bandage  exercises  upon  the  tissues,  and  the 
perfect  immobility  in  which  they  are  preserved,  hasten  very 
much  the  removal  of  this  condition.  He  treats  in  this  way 
comminuted  and  compound  fractures,  in  the  latter  cases 
leaving  the  wound  uncovered  by  the  bandage.  Unless  some 
symptom  occur  to  demand  the  removal  of  the  dressing,  M. 
Velpeau  does  not  disturb  it  until  the  fracture  has  become 
consolidated. 

M.  Laugier  employs  strong  paper  instead  of  muslin,  to 
envelope  the  limb.  He  cuts  this  paper  into  strips  arranged 
as.  in  the  bandage  of  Scultetus,  and  having  saturated  them 
with  the  agglutinating  mixture,  covers  the  limb,  including  the 
foot,  —  if  the  leg  be  broken,  —  forming  thus  a  firm  and  un- 
yielding boot.  This  plan  is  resorted  to  immediately,  and  the 
limb  inspected  from  time  to  time,  as  symptoms  call  for  it,  in 
which  event  the  apparatus  should  be  adjusted  accordingly. 

The  "Immovable  Apparatus"  may  be  very  advantageously 


TREATMENT  OF  FRACTURES.        115 

and  safely  used  in  the  treatment  of  fractures,  —  particularly 
of  the  upper  extremity,  and  of  the  leg, — after  the  injury  has 
been  treated  in  the  ordinary  way,  for  a  sufficient  time  to  have 
allowed  of  the  cessation  of  liability  to  displacement  of  the 
fragments;  in  other  words,  when  some  degree  of  firmness  has 
taken  place.  And  it  offers  this  great  advantage  over  all 
other  plans  of  treatment,  that  the  individual  upon  whom  it  is 
applied  may  be  permitted  to  walk  freely  with  the  aid  of 
crutches, — exercising  a  reasonable  caution,  of  course, — even 
with  a  broken  leg.  There  are  many  persons  who,  from  bad 
health,  or  from  the  pressing  requirements  of  business,  will 
not  bear  the  long  confinement  to  bed  which  the  ordinary 
modes  of  treating  a  fracture  of  the  lower  extremity  require : 
to  such  this  plan  is  very  happily  adapted,  suitable  care  being 
impressed  upon  them. 

If  this  method  is  resorted  to  from  the  first  occurrence  of 
the  fracture,  the  limb  should  be  carefully  inspected  daily,  and 
at  short  intervals  should  be  exposed,  particularly  until  it  has 
become  quite  stiff,  otherwise  an  irremediable  degree  of  de- 
formity may  have  occurred  unsuspected  by  the  surgeon,  or 
other  accidents  equally,  or  even  more,  serious. 

Another  variety  of  the  immovable  apparatus  has  been  re- 
commended by  M.  Dieffenbach,  of  Berlin.  It  is  made  of 
plaster,  poured  when  fluid  upon  the  part,  which  has  been  pre- 
viously denuded  of  hair  and  smeared  with  oil.  The  case  is 
made  in  several  pieces,  according  to  the  shape  of  the  limb, 
and  when  it  has  become  solidified  it  forms  a  very  unyielding 
envelope.  It  presents  the  same  advantages  and  disadvantages 
as  the  methods  already  alluded  to,  and  is  much  less  frequently 
employed  than  the  others.  (For  an  account  of  the  mode  in 
which  it  is  prepared  and  applied,  the  reader  is  referred  to 
Vidal  de  Cassis,  op.  cit.,  vol.  ii.  p.  240. — Paris,  1846.) 

The  second  plan  of  treating  fractures,  to  which  allusion 
has  been  made,  is  that  to  which  the  term  "Hyponarthecia" 
|has  been  applied  by  M.  Mayor,  of  Lausanne.  This  method 
was  first  recommended  by  M.  Sauter,  but  afterwards  more 
fully  developed  by  M.  Mayor.  The  apparatus  employed  con- 
sists of  a  piece  of  board,  somewhat  wider  and  longer  than 
that  division  of  the  limb  which  may  be  the  seat  of  the  frac- 
ture, and  covered  with  a  cushion  of  about  the  same  dimensions. 
The  cushion  is  stuffed  with  oat-chaff,  and  is  of  sufficient 


116  TREATMENT    OF    FRACTURES. 

thickness  to  allow  at  least  one-third  of  the  posterior  part  of 
the  circumference  of  the  limb  to  sink  into  it,  and  receive 
support  from  it.  The  fracture  having  been  reduced,  the  limb 
reposing  upon  the  cushion,  if  there  be  but  little  tendency  to 
displacement  of  the  fragments,  a  wide  cravat-shaped  bandage 
merely  is  made  to  embrace  both  the  splint  and  the  limb,  op- 
posite to  the  seat  of  the  injury ;  if  this  arrangement  be  found 
insufficient  to  retain  the  fragments  in  apposition,  extending 
and  counter-extending  cravat  bands  are  applied  to  the  limb 
below  and  above  the  fracture,  and  attached  to  corresponding 
extremities  of  the  board.  If  the  leg  be  broken,  the  extending 
band  is  made  to  act  upon  the  foot  and  ankle  and  confined  to 
a  foot-board,  while  the  counter-extension  is  made  upon  the 
leg  just  below  the  knee ;  any  disposition  to  lateral  displace- 
ment can  be  remedied  by  acting  upon  the  fragments  by  means 
of  cravats  passing  to  the  sides  of  the  board,  one  operating 
upon  the  upper  and  the  other  upon  the  lower  fragment ;  or  a 
single  cravat  may  be  so  applied  as  to  act  directly  upon  the 
angle  of  displacement,  and  having  its  "  point  d'appui"  upon 
the  opposite  side  of  the  board. 

This  apparatus  may  be  stationary,  or  it  may  be  suspended 
off  the  bed,  —  if  the  leg  be  broken, — by  means  of  cords  at- 
tached to  the  sides  of  the  board,  and  allowed  to  vibrate  gently 
in  the  air.  M.  Mayor  has  even  permitted  his  patients  to  sit 
up  in  chairs,  to  the  back  of  which  a  framework  is  attached 
arching  over  in  front,  with  the  apparatus  suspended  from  it. 
If  the  arm  be  broken,  the  apparatus  is  suspended  from  the 
neck  upon  the  chest,  and  the  limb  placed  upon  it  and  suitably 
confined  by  cravats. 

Under  the  head  of  special  fractures,  this  apparatus  will  be 
illustrated.  (See  fig.  53.) 

The  chief  advantages  which  M.  Mayor  claims  for  this 
method  of  treatment  are,  that  it  leaves  the  fractured  limb 
constantly  open  to  inspection,  that  it  is  very  simple  in  its  ar- 
rangement and  employment,  and  that  it  allows  of  a  certain 
degree  and  kind  of  movement  of  the  limb  as  a  whole,  with- 
out permitting  the  fragments  of  the  bone  to  become  displaced; 
this  last  proposition,  however,  admits  of  so  much  doubt  that, 
in  most  cases,  we  should  dissuade  from  the  employment  of 
M.  Mayor's  method,  considering  it  to  be  not  sufficiently 
secure;  indeed  the  very  fact  that  the  apparatus,  with  the 


TREATMENT  OP  FRACTURES.        117 

limb  upon  it,  is  allowed  to  execute,  and  is  even  arranged  for, 
a  degree  of  motion,  though  it  be  practised  gently  and  with 
caution,  renders  some  displacement  almost  certain. 

There  are  various  accidents  which  are  liable  to  occur,  and 
many  complications  to  be  met  with,  in  the  treatment  of  frac- 
tures, which  render  necessary  corresponding  modifications  of 
the  methods  ordinarily  pursued.  Such,  for  example,  are  ex- 
coriations, and  sloughings  of  different  parts  of  the  surface ; 
wounds  ;  a  tendency  to  particular  varieties  of  displacement : 
these  subjects  will  be  more  properly  attended  to  in  the  con- 
sideration of  special  fractures,  when  the  mode  of  obviating, 
or  remedying,  them  will  be  pointed  out.  As,  however,  it  is 
oftentimes  necessary  in  cases  of  fracture  to  subdue  inflamma- 
tion, it  will  be  convenient  to  state  here  that,  the  plan  to  be 
pursued  in  such  circumstances  is  to  apply  leeches  upon  the 
part,  if  required,  and  to  leave  the  surface  exposed,  as  much 
as  shall  be  consistent  with  the  proper  security  of  the  frag- 
ments, in  order  that  cooling  lotions  shall  be  laid  upon  it,  or 
other  local  antiphlogistic  applications. 

Before  proceeding  to  the  special  bandages  and  apparatus 
used  in  the  treatment  of  this  class  of  injuries,  it  will  be  pro- 
per to  allude  to  two  or  three  subjects  of  correlative  interest 
and  importance. 

When  an  individual  suffers  a  fracture  of  the  lower  ex- 
tremity, —  or  meets  with  any  injury  which  incapacitates  him 
for  walking,  the  proper  mode  of  removing  him  to  his  home, 
or  to  the  hospital,  is  a  serious  concern.  Generally,  it  is  ne- 
cessary, in  such  cases,  to  make  use  of  any  means  of  trans- 
portation which  shall  chance  to  present  itself,  as  a  window- 
shutter,  a  door,  or  a  settee ;  but  every  public  institution  for 
the  relief  of  the  sick  should  have  attached  to  it,  as  an  im- 
portant part  of  its  apparatus,  a  vehicle  contrived  expressly 
for  the  purpose.  This  may  be  made  like  the  ordinary  hand- 
barrow,  having  its  body  about  seven  feet  long  and  two  and  a 
half  or  three  feet  wide,  provided  with  a  slatted  or  sacking- 
bottom,  and  with  a  mattrass  and  cushions,  and  supported  off 
the  ground  upon  legs,  two  feet,  or  more,  in  length  :  when 
used  in  carrying  a  patient,  two  men  should  be  employed,  one 
to  sustain  each  extremity.  The  patient  should  be  extended 
upon  the  mattrass,  the  injured  part  comfortably  and  securely 
reposing  upon  the  cushions.  If  one  of  the  extremities  be 


118  TREATMENT    OF    FRACTURES. 

fractured,  or  otherwise  hurt,  the  limb  should  be  so  placed  as 
that  the  painful  action  of  the  muscles  shall  be  counteracted, 
as  much  as  possible,  by  position,  and  attention  should  be 
directed,  temporarily  at  least,  to  any  pressing  emergency,  — 
for  example,  to  the  existence  of  hemorrhage,  excessive  pain, 
syncope,  &c. 

The  part  which  is  the  seat  of  the  injury,  should  be  exposed 
very  gently  by  cutting  off  the  clothes  or  other  coverings  which 
envelope  it,  rather  than  by  drawing  them  away ;  the  panta- 
loons, for  instance,  should  be  ripped  along  the  outer  seam, 
and  the  boots  divided  in  the  most  convenient  manner  by  a 
knife.  In  cleansing  the  surface,  and  in  making  the  necessary 
examinations,  delicacy  of  manipulation  should  be  invariably 
studied,  and  the  infliction  of  any  unnecessary  pain  scrupu- 
lously avoided.  In  removing  the  patient  from  the  litter,  and 
in  placing  him  upon  the  bed,  the  same  care  should  be  exer- 
cised, the  injured  part  being  supported  by  the  surgeon 
himself. 

Not  the  least  important  desideratum  in  the  treatment  of 
those  fractures,  or  other  injuries,  which  require  that  the 
patient  shall  lie  perfectly  quiescent  for  a  considerable  length 
of  time,  is  a  proper  bed,  which  is  rarely  to  be  met  with.  The 
fracture-bed  in  general  use  is  an  ordinary  mattrass  firmly  and 
smoothly  filled,  and  having  a  circular  aperture  cut  through 
its  centre,  to  correspond  with  a  similar  aperture  in  the  sack- 
ing or  floor  of  the  bedstead.  When  the  patient  is  about  to 
have  an  evacuation,  the  cushion  which  covers  the  hole  in  the 
mattrass  is  removed,  and  a  suitable  vessel  made  to  slide  along 
a  double  groove,  placed  across  the  bottom  of  the  bedstead,  to 
receive  the  passage.  The  objections  to  this  bed  are  that,  the 
patient  is  obliged  to  raise  himself,  or  to  be  raised,  when  the 
cushion  is  withdrawn  and  replaced,  and  that  after  the  bed 
has  been  in  use  for  a  short  time,  it  sinks  very  much  in  the 
middle,  so  as  no  longer  to  present  a  flat  surface  to  support 
the  body  and  hips ;  both  of  these  are  serious  objections  and 
inconveniences.  They  may  be,  in  a  great  measure  at  least, 
obviated,  by  employing  a  bed  constructed  after  the  following 
method :  the  mattrass  should  be  very  firmly  and  evenly  filled 
with  hair ;  it  should  be  five  or  six  inches  in  thickness,  with 
the  margins,  or  border,  perpendicular,  about  seven  feet  long 
and  from  four  to  four  and  a  half  feet  wide.  An  oblong  sec- 


TREATMENT    OP    FRACTURES.  119 

tion  of  about  eight  inches  in  width,  and  extending  across  the 
middle  from  one  side  to  the  distance  of  a  few  inches  beyond 
the  median  line,  should  be  removed,  and,  after  having  been 
properly  prepared,  be  arranged  so  as  to  be  drawn  backwards 
and  forwards  at  pleasure  upon  the  floor  of  the  bedstead.  The 
bottom  of  the  bedstead  should  be  made  of  board,  and  should 
be  entire,  with  a  movable  section  opposite  that  of  the  mat- 
trass,  corresponding  with  it  in  length  and  breadth,  and  so 
adapted  as  always  to  aiford  a*  perfectly  firm  support  to  it, 
which  may  be  readily  accomplished  by  allowing  the  slat  to 
play  upon  a  double  groove.  When  an  evacuation  is  to  be 
received,  one  hand  of  the  attendant  should  be  placed  under- 
neath the  hip  of  the  patient,  and  the  section  of  the  bedstead 
and  of  the  mattrass  be  withdrawn  only  so  far  as  to  allow  the 
passage  to  take  place  freely,  while  the  hip  still  reposes  upon 
the  edge  of  the  section  of  the  mattrass  ;  the  vessel  for  receiv- 
ing the  evacuation  may  be  supported  in  any  convenient  man- 
ner underneath  the  bedstead.  Or  an  aperture  of  suitable  size 
to  permit  of  the  evacuation,  but  not  unnecessarily  large,  may 
be  cut  in  the  centre  of  the  mattrass,  and  the  portion  which 
was  removed  adapted,  by  a  hinge  joint  on  its  inferior  surface, 
to  close  the  aperture  when  the  evacuation  has  been  accom- 
plished, being  kept  closed  by  a  movable  strip  passing  across 
the  bedstead  and  constituting  part  of  its  floor. 
.  A  very  good  substitute  for  the  fracture-bed,  particularly 
for  children,  will  be  found  in  the  clinical  frame,  such  as  is 
described  in  the  Appendix  of  Cutler's  treatise  on  bandaging. 
It  consists  of  a  simple  framework,  of  two  longitudinal  and 
two  transverse  bars  attached  at  their  extremities,  about  seven 
feet  long  and  a  yard  wide ;  a  single  piece  of  canvass,  with  a 
circular  aperture  in  its  centre,  is  firmly  stretched  upon  it,  or 
several  strips  of  webbing  are  nailed  across  it,  intersecting 
each  other  in  various  directions,  but  leaving  a  sufficiently 
large  vacant  space  in  the  middle.  The  frame  thus  prepared 
is  habitually  placed  upon  the  mattrass,  having  been  pre- 
viously covered  with  a  sheet  in  the  centre  of  which  a  circular 
hole  has  been  cut,  and  the  patient  reposes  upon  it ;  when  he 
desires  to  have  a  passage,  the  frame  is  raised  sufficiently  off 
the  bed,  and  supported  in  this  position  in  any  convenient  and 
secure  manner,  while  the  evacuation  is  received  in  a  proper 
vessel.  The  frame  may  be  raised  by  two  attendants,  or  by 


120        TREATMENT  OF  FRACTURES. 

means  of  the  tripod  arrangement  of  Cutler,  which  consists  of 
three  strong  bars  united  by  a  hinge-joint  at  their  upper 
extremities,  and  having  an  iron  ring  or  hook  secured  to  their 
point  of  union  and  presenting  downwards :  through  this  ring 
a  long  lever  is  passed,  having  attached  to  one  end  of  it  the 
cords  by  which  the  frame  is  suspended,  while  the  force  for 
elevating  the  latter  is  exerted  upon  the  other  extremity  :  when 
the  frame  is  raised,  the  lever  may  be  secured  in  position  by 
cords  attached  to  some  fixed  point. 

The  apparatus  of  Jenks,  of  which  a  description  and  a 
drawing  are  given  in  Gibson's  Surgery,  vol.  i.,  is  more  com- 
plicated and  very  much  more  costly  than  the  simple  contri- 
vance above  described:  it  is,  however,  a  much  more  perfect 
arrangement,  and  should  be  introduced  into  every  hospital. 
But  in  private  practice  it  is  generally  sufficient  to  trust  to  the 
fracture-bed  for  adults,  and  to  the  simple  frame  described 
for  children,  who  can  be  lifted  from  the  bed  by  mere  muscular 
strength. 


CHAPTER  II. 

BANDAGES   AND   DRESSINGS   FOR   FRACTURES   OF   THE   BONES 
OF   THE   HEAD  AND   TRUNK. 


SECTION   I. 
FOR   FRACTURES    OF   THE    BONES    OF   THE    SKULL   AND   FACE. 

1.  WHEN,  in  fractures  of  the  cranial  bones  there  is  displace- 
ment of  the  fragments,  it  is  produced  by  the  violence,  what- 
ever this  may  have  been,  which  occasioned  the  solution  of 
continuity,  and  not,  as  in  similar  injuries  of  the  long  bones, 
by  muscular  action.     Hence,  after  the  displacement  has  been 
remedied, — if  it  be  necessary,  or  advisable  to  attempt  it, — 
bandages  are  only  required  for  the  purpose  of  protecting  the 
injured  parts  from  external  irritation,  and  of  retaining  such 
dressings  as  may  be  applied ;  they  are,  therefore,  very  simple, 
as  for  example,  strips  of  adhesive  plaster,  the  triangle  of  Mayor, 
the  T  bandage,  or  an  ordinary  night-cap,  or  finally,  the  recur- 
rent bandage : — these  have  already  been  described. 

2.  Generally,  the  same  remarks  may  be  extended  to  frac- 
tures of  the  facial  bones,  those  of  the  nose  for  instance :  the 
fragments  having  been  restored  as  well  as  possible,  to  their 
natural  positions,  they  need  no  bandages  to  preserve  them 
"in  situ;"  the  latter  are  serviceable  only  as  retentive  or  pro- 
tective means. 

3.  In  fractures  of  the  inferior  maxillary  bone,  however,  the 
fragments  are  almost  always  displaced,  and  retained  in  their 
abnormal  situations,  by  the  direct  action  of  the  muscles  which 
are  connected  with  them,  as  the  digastric,  the  hyoid,  the  pte- 
rygoid  muscles,  &c.,  &c. ;  it  becomes  necessary,  consequently, 
to  employ  some  kind  of  bandage  or  apparatus  which  shall  coun- 
teract the  influence  of  these  displacing  agents. 

The  bandages  most  frequently  used  for  this  purpose,  and 
which  will  probably  be  found  sufficient  in  all  cases, — are  the 
11  (m) 


122       FRACTURES    OF    THE    SKULL    AND    FACE. 

four-tailed  of  the  chin,  and  those  of  Drs.  Gibson  and  Barton, 
of  this  city. 

1.  The  four-tailed  bandage  of  the  chin. 
COMPOSITION. — An  oblong  piece  of  stout  pasteboard  divided 

at  each  end  to  within  an  inch  of  the  middle  ; — a  four-taUed 
bandage,  prepared  as  directed  in  the  section  on  bandages  of 
the  head  ; — compresses. 

APPLICATION. — The  pasteboard,  previously  softened  by  im- 
mersion in  hot  water  and  moulded  to  the  form  of  the  chin  and 
jaw,  (fig.  41,)  is  applied  upon  the  seat  of 
FIG.  41.  fracture  ;  then  the  middle  portion  of  the 

bandage  is  placed  upon  the  chin,  over  the 
splint ;  the  two  superior  tails,  a,  «,  fig. 
20,  are  carried,  one  on  each  side,  towards 
the  nape  of  the  neck,  where  they  are 
crossed,  and  then  conducted,  one  along 
each  side  of  the  head,  obliquely  upwards 
and  forwards  to  the  forehead,  and  pinned  ; 
the  lower  tails,  6,  &,  are  now  carried  upwards  before  the  ears, 
to  the  summit  of  the  head,  where  they  in  turn  are  crossed, 
and  then  returned  and  confined  beneath  the  chin.  (Cutler, 
p.  70.) 

2.  The  bandage  of  Professor  Gibson,  and  its  application  are 
thus  described  by  the  author  himself:  "The  surgeon  having 
carefully  examined  the  injured  parts,  and  replaced  such  teeth 
as  may  have  been  shaken  or  loosened,  runs  his  finger  along 
the  margin  of  the  jaw,  models  the  parts  to  a  proper  shape,  and 
closes  the  mouth  firmly,  making  the  lower  teeth  press  fairly 
against  the  upper.     Then  a  cotton  or  linen  compress  of  mode- 
rate thickness,  reaching  from  the  angle  of  the  jaw  nearly  to 
the  chin,  is  placed  beneath  and  held  by  an  assistant,  while  the 
surgeon  takes  a  roller,  four  or  five  yards  long  and  an  inch  and 
a  half  wide,  and  passes  it  by  several  successive  turns  under 
the  jaw,  up  along  the  sides  of  the  face  and  over  the  head ; 
now  changing  the  course  of  the  bandage,  he  causes  it  to  pass 
off  at  a  right  angle  from  the  perpendicular  cast,  and  to  encir- 
cle the  temple,  occiput,  and  forehead  horizontally  by  several 
turns ;  finally,  to  render  the  whole  more  secure,  several  addi- 
tional horizontal  turns  are  made  around  the  back  of  the  neck, 
under  the  ear,  along  the  base  of  the  jaw,  and  over  the  point 
of  the  chin.     To  prevent  the  roller  from  slipping  or  changing 


FRACTURES  OF  THE  SKULL  AND  FACE.   123 

its  position,  a  short  strip  may  be  secured  by  a  pin  to  the  hori- 
zontal turn  that  encircles  the  forehead,  and  passed  backwards 
along  the  centre  of  the  head  as  far  as  the  neck,  where  it  must 
be  tacked  to  the  lower  horizontal  turn, — care  being  taken  to 
insert  pins  at  every  point  at  which  the  roller  has  crossed. 
This  simple  method  of  securing  a  fractured  jaw  I  have  prac- 
ticed very  successfully  for  several  years."  (Fig.  42.) 

3.  Dr.  J.  R.  Barton's  bandage. 

COMPOSITION. — A  roller  five  yards  long  and  two  inches 
wide ;  suitable  compresses. 

APPLICATION. — Place  the  initial  extremity  of  the  roller  upon 
the  occiput  just  below  its  protuberance,  and  conduct  the  cy- 
linder obliquely  over  the  centre  of  the  left  parietal  bone  to  the 
top  of  the  head ;  thence  descend  across  the  right  temple  and 
the  zygomatic  arch,  and  pass  beneath  the  chin  to  the  left  side 


FIG.  42. 


FIG.  43. 


of  the  face ;  mount  over  the  left  zygoma  and  temple  to  the 
summit  of  the  cranium,  and  regain  the  starting-point  at  the 
occiput  by  traversing  obliquely  the  right  parietal  bone ;  next 
wind  around  the  base  of  the  lower  jaw  on  the  left  side  to  the 
chin,  and  thence  return  to  the  occiput  along  the  right  side  of 
the  maxilla ;  repeat  the  same  course,  step  by  step,  until  the 
roller  is  spent,  and  then  confine  its  terminal  end.  (Fig.  43.) 

These  bandages  are  easily  applied,  and  are  very  efficacious; 
the  pasteboard  splint  described  in  connexion  with  the  first, 


124   FRACTURES  OF  THE  BONES  OF  THE  TRUNK. 

will  be  found  to  be  a  very  useful  adjunct  to  the  two  latter. 
The  bandage  may  be  made  to  act  upon  any  particular  portion 
of  the  jaw,  as  required  by  the  situation  of  the  fracture,  by  mo- 
difying slightly  the  course  of  the  roller  in  its  successive  turns, 
and  by  a  proper  position  of  the  compresses ;  a  little  reflection 
on  the  part  of  the  dresser  will  enable  him  to  adapt  his  means 
of  treatment  to  the  ends  indicated  in  each  case. 

Mr.  Lonsdale  invented  a  complicated  apparatus  for  the 
treatment  of  a  particular  case  of  fracture  at  the  symphysis  of 
the  lower  jaw,  in  which  much  difficulty  was  experienced.  He 
found  it  to  answer  perfectly  in  this  instance,  and  in  several 
other  cases  which  occurred  afterwards.  The  ends  which  he 
had  in  view,  and  which  he  gained  by  this  apparatus,  were  "  to 
apply  all  the  force  and  pressure  to  the  lower  jaw  alone  ;  to  fix 
the  two  portions  of  bone  between  two  parallel  forces,  by  ap- 
plying one  on  the  teeth,  and  the  other  under  the  base  of  the 
jaw  ;  lastly,  to  keep  the  two  portions  of  bone  on  the  same  ver- 
tical plane,  by  fixing  them  in  a  grooved  plate  placed  along  the 
teeth."  For  the  description  and  illustration  of  Mr.  Lonsdale's 
apparatus,  the  reader  is  referred  to  this  gentleman's  "  Practi- 
cal Treatise  on  Fractures,"  p.  234,  et  seq. ;  or  to  Mr.  Cutler's 
book,  p.  71,  et  seq. 

If  the  fracture  be  compound,  or  in  a  simple  fracture  com- 
plicated with  a  wound  of  the  cheek,  or  chin,  the  folds  of  the 
bandage  must  be  so  arranged  as  not  to  press  with  too  much 
force  directly  upon  the  wound,  and  to  allow  of  the  applica- 
tion of  suitable  dressings,  of  which  the  first  object  is  to  pro- 
mote immediate  closure  of  the  wound. 


SECTION    II. 
BANDAGES   FOR   FRACTURES   OF   THE   BONES    OF   THE   TRUNK. 

1.  For  fractures  of  the  vertebra. 

The  bones  of  the  spinal  column  are  very  much  screened 
and  protected  from  fracture  by  their  peculiar  shape  and  situ- 
ation ;  hence  they  are  rarely  broken.  When  they  are  thus 
injured,  it  is  most  frequently  the  spinous  process  which  suffers, 
as  being  the  most  exposed,  and,  from  its  form  and  structure, 


FRACTURES  OF  THE  BONES  OF  THE  TRUNK.   125 

the  most  readily  broken.  But  very  little  displacement  fol- 
lows when  it  is  fractured,  since  it  is  imbedded  in  muscles  and 
ligaments,  and  acted  upon  with  equal  force  from  both  sides. 
A  bandsige  is  not,  therefore,  really  needed  in  cases  of  this 
kind ;  it  is  very  proper,  however,  to  make  use  of  the  roller, 
as  exhibited  in  fig.  29,  or  of  the  laced  bandage  of  the  chest, 
already  described,  with  compresses  placed  upon  the  spinous 
process,  in  order  to  insure  perfect  apposition  of  the  frag- 
ments, and  to  prevent  injury  from  the  movements  of  the  pa- 
tient in  bed.  The  injury  done  to  the  spinal  medulla  is  gene- 
rally such  as  to  demand  more  attention  on  the  part  of  the 
surgeon  than  the  mere  fracture.  The  condition  of  the  blad- 
der, especially,  will  require  watchfulness,  retention  of  urine 
being  a  very  common  accompaniment  of  the  accident,  and 
demanding  the  introduction  of  the  catheter  at  least  twice  daily. 
Sloughing  of  the  integuments,  wherever  pressure  falls,  is  also 
a  troublesome  complication,  and  one  which  should  be  pre- 
vented, if  possible,  by  frictions  of  such  parts,  and  by  the  proper 
adjustment  of  pillows. 

2.  For  fractures  of  the  ribs  and  sternum. 

A  little  reflection  upon  the  shape  and  connexions  of  these 
bones  will  show  that  there  cannot,  as  a  general  rule,  be  much 
displacement  of  their  fragments  when  they  are  broken.  The 
ribs  are  attached  to  each  other  both  above  and  below,  and 
throughout  their  entire  length,  by  the  intercostal  muscles ; 
they  are  strongly  bound  to  the  vertebrse,  and  Connected  to  the 
sternum  in  front  by  a  very  elastic  tissue  ;  while  the  sternum  is 
itself  securely  united  to  the  clavicles,  and  retained  "in  relief," 
as  it  were,  by  the  numerous  costal  arches  which  subtend  it  on 
each  side.  Thus  the  whole,  and  each  part,  are  so  elastic  that 
they  regain  their  original  shape,  when  this  has  been  altered 
in  case  of  fracture,  unless  the  fragments  are  driven  into  the 
cavity  of  the  chest  by  great  violence. 

The  general  indication  of  treatment  in  fractures  of  the  ribs 
and  sternum  is  to  prevent,  as  much  as  practicable,  the  play 
of  the  thoracic  respiratory  muscles,  devolving  the  perform- 
ance of  the  mechanical  acts  of  respiration  upon  the  diaphragm, 
thereby  preserving  the  broken  bones  in  a  state  of  comparative 
repose.  To  accomplish  this,  compresses  and  a  bandage  of 
some  sort  are  necessary.  The  laced  or  buckled  bandage  of 
the  chest  will  answer  very  well  in  many  cases,  but  generally 


126      FRACTURES    OF   THE   BONES   OF   THE   TRUNK. 

the  roller  is  to  be  preferred.  Its  application  should  be  com- 
menced from  below,  the  patient  having  previously  made  a 
forcible  expiration ;  the  roller  should  ascend  to  the  axilla  by 
circular  turns,  made  with  considerable  tightness,  and  then 
pass  obliquely  upwards  and  outwards  from  the  axilla  to  the 
root  of  the  neck  on  the  opposite  side,  and  down  in  front  of 
the  chest,  crossing  the  circular  folds  of  the  bandage  which  it 
serves  to  secure  by  means  of  pins  inserted  at  intervals.  The 
roller  for  this  bandage  should  be  about  eight  yards  long  and 
three  inches  wide. 

The  proper  disposition  of  the  compresses  is  a  matter  of 
much  importance  in  the  treatment  of  these  fractures.  If  a 
rib  has  been  broken  by  force  acting  upon  its  anterior  portion, 
the  solution  of  continuity  has  occurred  probably  near  the 
angle,  where  the  anterior  and  posterior  curves  meet ;  the  first 
effect  of  the  violence  has  been  to  increase  the  bend  of  the 
rib  at  this  region,  and  finally  to  rupture  its  fibres;  of  course 
there  will  be  an  angular  displacement  externally,  and  the 
compress  should  be  applied  either  directly  over  the  fracture, 
or  one  should  be  placed  a  little  anteriorly  and  another  just 
posteriorly  to  it.  But  when  the  force  impinges  upon  the 
angle  or  side  of  the  rib,  if  there  be  any  displacement  appre- 
ciable, it  is  probably  towards  the  cavity  of  the  chest,  and  the 
compresses  should  be  so  placed  as  to  restore,  if  possible,  the 
natural  curve  of  the  bone,  and  thus  to  throw  the  fragments 
outwards.  To  effect  this  object,  apply  one  compress  upon 
the  rib  near  its  junction  with  its  cartilage,  and  another  near 
its  angle,  as  far  posteriorly  as  may  be ;  or,  as  Mr.  Lonsdale 
advises,  a  broad  lath  or  piece  of  pasteboard,  may  be  laid 
upon  the  side  of  the  chest  and  confined  by  a  roller,  being 
made  to  press  with  especial  force  upon  points  remote  from  the 
seat  of  fracture. 

If  the  sternum  has  been  broken,  and  there  be  depression 
of  one  of  the  fragments,  a  compress  should  be  laid  upon  the 
portion  which  is  not  depressed,  near  the  line  of  fracture,  and 
another  upon  the  depressed  portion  of  the  bone  at  a  point 
remote  from  the  rupture,  so  that,  when  the  roller  is  made  to 
act  forcibly  upon  the  two,  the  first  fragment  will  be  depressed 
and  the  other  elevated,  at  the  broken  margin. 

The  bandage  should  be  worn  four  or  five  weeks. 

3.  For  fractures  of  the  pelvic  bones.     These  bones  are 


FRACTURES  OF  THE  BONES  OF  THE  TRUNK.  127 

very  rarely  broken,  and  they  are  so  enveloped,  individually 
and  collectively,  in  muscular  and  ligamentous  expansions 
covering  their  whole  surfaces,  that  in  the  event  of  fracture 
there  can  be  but  slight  displacement,  unless  when  the  frag- 
ments are  violently  forced  inwards. 

The  indication  for  the  treatment  is,  of  course,  to  keep  the 
fragments  at  rest.  To  accomplish  this  a  broad  roller  should 
be  passed  firmly  around  the  upper  part  of  the  thighs  and  the 
pelvis,  and  compresses  judiciously  applied  to  enable  the  band- 
age to  act  upon  particular  points,  as  may  be  required.  Per- 
fect quiescence  should  be  enjoined  upon  the  patient  for  a 
length  of  time,  —  from  two  to  two  and  a  half  months.  The 
state  of  the  bladder  must  be  carefully  attended  to. 

In  cases  of  compound  fracture  of  the  bones  of  the  head 
and  trunk,  the  dressings  must  be  so  applied  as  not  to  press 
with  too  much  force  upon  parts  surrounding  the  wound,  other- 
wise sloughing  of  the  integuments  may  ensue.  The  bandage 
should  cover  the  wound  very  lightly,  in  order  that  suitable 
applications  may  be  made  to  it :  it  is  better  indeed  that  the 
bandage  for  the  fracture  itself  shall  leave  the  wound  exposed, 
and  that  an  additional  retentive  band  be  employed  for  such 
dressings  as  may  be  called  for. 


CHAPTER  III. 

ON  THE  APPARATUS  AND  DRESSINGS  FOR  FRACTURES  OF  THE 

BONES  OF  THE  SHOULDER. 

• 

SECTION   I. 
FOR    FRACTURES    OF    THE    CLAVICLE. 

THE  slender  proportions  and  exposed  situations  of  this 
bone  render  it  very  liable  to  be  broken ;  and  in  the  great 
majority  of  instances  a  considerable  degree  of  displacement 
accompanies  the  fracture ;  the  exceptional  cases  are  those  in 
which  the  solution  of  continuity  has  occurred  at  the  acromial 
extremity  of  the  bone,  where  the  surface  is  broad  and  covered 
with  ligamentous  expansions.  But  when,  as  generally  hap- 
pens, the  fracture  has  involved  the  more  central  portions  of 
the  clavicle,  an  angular  deformity  is  produced,  presenting  an- 
teriorly, the  scapular  fragment  being  dragged  downwards  by 
the  weight  of  the  arm,  and  drawn  towards  the  median  line 
of  the  chest,  in  front,  by  the  action  of  the  pectoral  muscles ; 
the  sternal  fragment  is  but  little  deviated  from  its  natural 
position,  being  held  in  place  by  the  combined  but  counteract- 
ing forces  pf  the  sterno-clavicular  and  costo-clavicular  liga- 
ments, and  of  the  sterno-cleido-mastoid  muscle;  the  promi- 
nence seen  and  felt  at  the  point  of  fracture  is  due,  in  most 
cases  to  the  sternal  fragment,  the  scapular  portion  being 
drawn  rather  below  and  behind  the  other ;  sometimes,  how- 
ever, the  scapular  fragment  projects  in  advance  of  the  ster- 
nal. The  fracture  is  usually  oblique  and  simple ;  comminuted 
and  compound  fractures  occur,  however,  at  times. 

The  indication  to  be  pursued  in  the  treatment  of  this  injury /' 
is,  of  course,  to  reverse  the  line  of  displacement  of  the  sea-* 
pular  segment  of  the  bone ;  viz.,  to  force  the  shoulder,  and 
with  it  the  fragment  of  the  clavicle  which  is  attached  to  it, 
upwards,  outwards,  and  backwards ;  and  having  thus  restored 

(128) 


FRACTURES    OF    THE    CLAVICLE.  129 

the  natural  form  of  the  clavicle,  to  retain  the  parts  in  this 
position  until  consolidation  of  the  fracture  shall  have  taken 
place.  The  first,  or  the  reduction,  is  not  difficult ;  the  last 
demands  constant  care  from  the  surgeon,  and  a  well-contrived 
apparatus.  In  regard  to  this,  M.  Vidal  (de  Cassis)  says  — 
"fracture  of  the  clavicle  is  almost  always  followed  by  de- 
formity ;"  and  he  adds  very  truly,  "  but  this  deformity  is  not 
attended  with  much  inconvenience,  and  does  not  seriously 
impair  the  movements  of  the  limb."  In  females  particularly, 
however,  a  deformity  in  so  exposed  a  situation  as  this,  must 
be  unpleasant,  and  every  endeavour  should  be  made  to  pre- 
vent its  occurrence. 

It  is  interesting  to  trace  the  progressive  steps  which  have 
been  made  in  the  treatment  of  this  injury.  u  Hippocrates 
considered  it  necessary  merely  to  draw  the  shoulder  outwards 
and  backwards.  With  this  view  he  directed  the  patient  to 
lie  upon  some  prominent  body,  the  back  only  being  sup- 
ported, while  the  shoulders  were  forced  backwards  and  out- 
wards by  their  simple  weight.  Paulus  OEgineta,  in  addition 
to  this,  placed  a  pad  in  the  axilla.  Guy  de  Chauliac  en- 
deavoured to  fulfil  the  same  indication  by  means  of  a  bandage 
applied  around  the  shoulders  in  the  form  of  the  figure  8, 
which  plan  was  generally  adopted,  and  of  which  many  sur- 
geons recommended  modifications  without,  however,  increasing 
its  efficacy."  (See  Yidal  de  Cassis,  op.  cit.,  vol.  ii.  p.  291, 
et  seq.)  Thus  from  time  to  time,  until  the  present  day,  many 
varieties  of  apparatus,  some  of  them  very  complicated,  pos- 
sessing different  degrees  of  excellence,  have  been  contrived 
for  the  treatment  of  fractures  of  the  clavicle.  •  It  was  re- 
served, however,  for  one  of  our  own  countrymen,  a  surgeon 
of  this  city,  Dr.  George  Fox, — to  invent,  in  the  year  1828, 
an  apparatus  which  admirably  fulfils  every  indication,  is  very 
simple  in  its  construction  and  application,  is  more  comfort- 
ably borne,  perhaps,  than  any  other,  and  yet  leaves  the  in- 
jured clavicle  freely  and  constantly  exposed  to  the  view  of 
the  surgeon,  and  for  the  application  of  topical  remedies,  if 
required. 

The  apparatus  of  Dr.  Fox  consists  of  a  firmly  stuffed  pad 
of  a  wedge  shape,  and  about  half  as  long  as  the  humerus, 
having  a  band  attached  to  each  extremity  of  its  upper  or 
thickest  margin :  a  sling  to  suspend  the  elbow  and  fore-arm, 


130  FRACTURES    OF    THE    CLAVICLE. 

made  of  strong  muslin,  with  a  cord  attached  to  the  humeral 
extremity,  and  another  to  each  end  of  the  carpal  portion ; 
and  a  ring  made  of  muslin  stuffed  with  cotton  to  encircle  the 
sound  shoulder,  and  serve  as  means  of  acting  upon  and  se- 
curing the  sling.  The  apparatus  is  applied  thus : — Pass  the 
arm  of  the  uninjured  side  through  the  ring,  so  that  the  latter 
may  surround  the  shoulder ;  press  the  thick  end  of  the  pad 
firmly  against  the  summit  of  the  axilla  of  the  affected  side, 
and  carry  the  bands  which  are  attached  to  it,  one  in  front  of 
and  the  other  behind  the  corresponding  shoulder,  to  cross 
upon  the  root  of  the  neck  and  traverse  the  chest  obliquely, 
before  and  behind,  and  to  be  tied  to  the  ring ;  then  having 
fixed  the  elbow  and  the  fore-arm  corresponding  with  the  frac- 
tured clavicle  in  the  sling,  conduct  its  posterior  cord  behind 
the  thorax,  and  the  two  anterior  cords  in  front  of  it,  and 
secure  them  to  the  ring.  The  shoulder  can  be  operated  upon 
very  powerfully  by  means  of  these  cords ;  it  can  be  thrown 
upwards,  or  backwards  and  outwards,  to  any  required  degree, 
and  one  of  these  motions  can  be  impressed  upon  it  at  plea- 
sure, until  the  surgeon  shall  be  satisfied  with  the  position  of 
the  fragments. 

Soft  pads  of  cotton  should  be  interposed  between  the  sur- 
face and  the  apparatus  at  different  points ;  and,  from  time  to 
time,  when  the  surgeon  re-arranges  the  dressings,  he  should 
endeavour  to  make  the  pressure  bear  upon  parts  of  the  sur- 
face which  have  not  previously,  or  recently,  been  acted  upon. 
The  point  of  the  elbow  will  require  protection  in  this  way ; 
frequently  it  is  well  to  make  a  circular  aperture  in  the  sling 
and,  having  covered  it  with  a  flattened  mass  of  cotton,  to 
allow  the  point  of  the  elbow  to  sink  into  it. 

If  the  fracture  is  comminuted,  a  compress  may  be  placed 
over  the  fragments,  to  assist  in  the  securing  of  perfect  appo- 
sition. 

Fractures  of  the  clavicle,  treated  by  this  apparatus,  are 
daily  dismissed  from  the  Pennsylvania  Hospital,  and  by  sur- 
geons in  private  practice,  cured  without  perceptible  deform- 
ity ;  and  no  one  who  has  employed  it  will  be  disposed  to  use 
any  other  as  a  substitute. 

The  annexed  drawing  exhibits  this  dressing  as  applied. 
(Fig.  44.)  A  mere  inspection  of  it  will  show  the  advantages 
,>f  this  apparatus  over  all  others,  in  the  complete  performance 


FRACTURES    OF    THE    CLAVICLE. 


131 


FIG.  44. 


of  the  requisite  revolutions  of  the  shoulder,  the  exposure  of 
the  injured  parts,  its 
lightness,  and  the  avoid- 
ance of  impediment  to 
respiration,  and  of  pres- 
sure upon  the  mammary 
glands  when  it  is  applied 
to  females ;  in  each  of 
these  particulars  the  com- 
plicated bandage  of  Des- 
sault,  which  is  still  used 
by  some  surgeons,  is  open 
to  serious  objection ;  the 
same  remark  is  likewise 
applicable  to  the  plan  of 
treatment  recommended 
and  illustrated  by  M. 
Velpeau  (op.  cit.,  vol.  i. 
p.  229) ;  indeed  this  must 
be  less  efficacious  than 
the  other,  since  it  merely  confines,  by  means  of  a  roller,  the 
hand  corresponding  with  the  broken  clavicle  upon  the  sound 
shoulder,  no  pad  being 
placed  in  the  axilla  to 
force  the  scapular  frag- 
ment outwards.  (See  fig. 
46.) 

*  As  a  temporary  band- 
age, to  be  employed 
during  the  short  time  ne- 
cessary for  the  prepara- 
tion of  Fox's  apparatus, 
if  the  surgeon  have  not 
one  already  made,  that 
recommended  by  Mr. 
Lonsdale  may  be  used.  A 
pad,  resembling  in  shape 
that  already  described,  is 
to  be  secured  in  the  axilla  by  means  of  a  roller.  "  The  elbow 
is  next  to  be  brought  before  the  chest  as  far  as  possible,  and 
to  be  held  there,  while  a  few  turns  of  the  roller  are  passed 


FIG.  45. 


132  FRACTURES    OF    THE    CLAVICLE. 

around  to  confine  it  to  the  thorax ;  a  sling  is  then  to  be 
applied,  which  must  be  made  very  short,  so  as  to  prevent  the 
elbow  from  falling  from  the  position  into  which  it  has  been 
brought,  for  upon  this  depends  the  whole  action  of  the  hume- 
rus  on  the  scapular  end  of  the  clavicle."  (Lonsdale,  op.  cit., 
pp.  212,  213.)  (Fig.  45.) 

A  bandage  very  similar  to  this  was  described  by  Dr.  Brown, 
of  New  York,  in  the  Philadelphia  Medical  Recorder  of  1821. 
It  requires  that  a  pad  of  a  wedge  shape  shall  be  confined  in 
the  axilla  by  means  of  a  roller,  which  also  fixes  the  fore-arm, 
previously  flexed  at  an  acute  angle  upon  the  breast,  leaving 
the  wrist  and  hand  to  be  supported  by  a  sling.  This  band- 
age is  described  in  detail  and  illustrated  by  a  drawing  in  the 
Medical  Recorder,  as  above  mentioned. 

Many  other  plans  of  treatment  have  been  proposed  and 
resorted  to,  but  the  apparatus  of  Fox  will  be  found  of  itself 
sufficient  for  all  cases  which  may  occur.  Latterly,  an  en- 
tirely novel  method  has  been  instituted  in  France  by  M. 
Guillou ;  this  gentleman  reported  it  to  the  Academy  of  Sci- 
ences of  Paris,  and  the  description  of  his  mode  of  treatment 
was  published  in  full  in  "  L'Abeille  Medicale,"  for  October, 
1847  ;  the  following  summary  is  taken  from  that  journal : 

The  apparatus  consists  of  five  pieces,  —  1st,  of  a  sling 
made  of  a  handkerchief  of  proper  length ;  2d,  of  a  cravat 
folded  in  the  middle ;  3d,  of  a  body-bandage  formed  of  a 
towel;  4th,  of  a  square  cushion  of  linen,  thicker  in  the 
middle  than  along  the  margin  ;  5th,  of  a  pad  for  the  axilla, 
having  a  band  of  about  a  foot  and  a  half  long  attached  to  its 
base  on  each  side. 

In  the  adjustment  of  the  apparatus,  the  pad  is  placed  in 
the  axilla  of  the  injured  side,  and  secured  in  this  position  by 
crossing  its  bands  upon  the  sound  shoulder;  the  forearm  is 
then  thrown  behind  the  back  and  supported  by  the  sling, 
which  is  passed  around  the  neck,  and  made  longer  or  shorter, 
according  to  the  degree  of  force  which  it  may  bev  necessary 
to  exert  upon  the  external  fragment  of  the  clavicle,  since  the 
more  the  fore-arm  is  raised,  the  more  the  external  fragment 
will  be  thrown  outwards,  backwards,  and  upwards ;  in  order 
to  confine  the  arm  securely  in  this  position,  the  body-bandage 
is  applied,  to  compress  the  lower  part  of  the  humerus  against 
the  thorax,  while  the  cravat  band  acts  in  a  similar  manner 


FRACTURES    OF    THE    SCAPULA.  133 

upon  the  upper  portion  of  the  arm,  being  wrapped  around 
this  part  of  the  humerus,  and  fastened  upon  the  sound 
shoulder ;  to  increase  the  power  of  the  cravat,  the  square 
cushion  is  inserted  between  it  and  the  back,  and  the  cravat 
and  the  body-bandage  are  pinned  to  it. 

M.  Guillou  has  employed  this  method  of  treatment  for 
some  years,  and  prefers  it  to  all  others. 

The  author  has  treated  several  cases  of  fracture  of  the 
clavicle  after  this  method,  and  has  found  it  to  accomplish  all 
the  indications  as  well  as  Fox's  apparatus.  It  is,  however, 
rather  more  irksome  to  the  patient,  during  the  first  few  days, 
than  the  dressing  of  Dr.  Fox.  The  pieces  composing  the 
latter  apparatus  may  be  used  instead  of  those  described  by 
M.  Guillou. 

The  duration  of  treatment  of  cases  of  simple  fracture  of 
the  clavicle  may  be  stated  at  six  or  eight  weeks. 


SECTION  II. 
FOR   FRACTURES    OF   THE    SCAPULA. 

Viewing  merely  the  prominent  situation  of  the  scapula,  and 
its  rather  delicate  physical  conformation,  one  would  fancy 
that  it  was  particularly  subject  to  breakage;  but  this  is  not 
really  the  case.  It  reposes  upon  a  soft  and  yielding  bed  of 
muscular  tissue,  and  is  covered  by  the  same  sort  of  structure, 
so  that  any  force  which  acts  upon  the  scapular  region  is  de- 
prived of  a  large  part  of  its  capacity  to  injure,  before  its  in- 
fluence has  extended  to  the  bone  itself.  Even  its  projecting 
processes,  little  adapted  as  they  are  in  themselves  to  resist 
violence,  are  sheltered  and  protected  in  the  same  way. 

The  parts  of  the  scapula  which  are  most  often  broken  are, 
in  the  order  of  frequency,  the  acromion  process,  the  inferior 
angle  of  the  bone,  the  body,  the  coracoid  process,  and,  finally, 
the  neck. 

1.  Of  the  body  and  inferior  angle. 

When  the  body  of  the  scapula  is  fractured  either  obliquely 
or  transversely,  there  cannot  be  much  separation  or  displace- 
ment of  the  fragments,  since  its  whole  surface,  both  in  front 
ind  posteriorly,  is  covered  by  an  expansion  of  muscular 
12 


134       FRACTURES  OF  THE  SCAPULA. 

fibres,  having  an  attachment  around  the  margin  of  the  bone. 
The  indication  to  be  kept  in  view,  therefore,  in  the  treatment 
of  this  accident,  is  merely  to  maintain  the  fragments  at  rest, 
by  preventing  the  action  of  the  muscles  which  operate  upon 
them  directly  and  indirectly.  This  object  is  readily  and 
completely  attained,  by  applying  over  the  body  of  the  scapula 
a  broad  compress,  and  securing  it  in  this  situation  by  passing 
a  wide  roller  around  the  chest ;  the  arm  should  be  kept  at  rest 
in  the  flexed  position,  supported  in  a  sling,  and  confined  upon 
the  breast. 

When  a  fracture  separates  the  inferior  angle  from  its  con- 
nexion with  the  body  of  the  scapula,  the  former  is  more  or 
less  drawn  away  from  the  latter  by  the  action  of  the  teres 
major  muscle.  Hence,  in  the  treatment  of  this  fracture,  the 
arm  should  be  carried  backwards  towards  the  scapula,  in  order 
to  relax  this  muscle,  and  confined  in  this  position  by  means 
of  a  broad  roller,  which  shall  likewise  press  upon  the  body  of 
the  bone  and  its  inferior  angle, —  the  fragments  having  been 
put  in  apposition, —  by  the  intervention  of  compresses  placed 
directly  upon  these  parts.  The  fore-arm  should  be  supported 
by  a  sling. 

2.  Of  the  coracoid  process. 

This  portion  of  the  scapula  is  placed  very  much  out  of  the 
reach  of  injury,  yet  i't  is  occasionally  broken.  When  frac- 
tured, a  certain  amount  of  displacement  will  probably  occur 
as  a  result  of  the  action  of  the  three  muscles  attached  to  it, 
viz.,  the  pectoralis  minor,  the  coraco-brachialis,  and  the  short 
head  of  the  biceps,  whose  combined  agency  will  drag  the  frag- 
ment downwards  and  somewhat  inwards,  towards  the  point  of 
origin  of  the  smaller  pectoral  muscle. 

To  re-adjust  the  fragments,  the  above-named  muscles  must 
be  relaxed,  and  some  small  compression  made  over  the  broken 
process.  The  fore-arm  should  be  flexed  to  an  acute  angle  and 
supported  upon  the  breast,  the  hand  of  the  injured  side  rest- 
ing upon  the  sound  shoulder,  while  a  graduated  compress  is 
confined  over  the  natural  situation  of  the  coracoid  process  by 
means  of  the  spica  bandage  (fig.  37).  Or  the  bandage  which 
M.  Velpeau  recommends  for  the  treatment  of  fractures  of  the 
clavicle  (op.  cit.,  p.  229),  will  fulfil  the  same  indications  very 
well ;  thus :  select  a  roller  from  ten  to  twelve  yards  long  and 
two  and  a  half  inches  wide,  and  apply  its  initial  extremity  to 


FRACTURES  OF  THE  SCAPULA. 


135 


the  axilla  of  the  sound  side ;  then  conduct  the  cylinder 
obliquely  upwards  over  the  back  to  the  affected  shoulder, 
place  the  hand  of  this  side  upon  the  opposite  shoulder,  the 
fore-arm  reposing  upon  the  chest,  and  continue  the  roller  over 
the  clavicle  of  the  injured  side,  across  the  upper  part  of  the 
arm  to  the  outside  of  the  same,  and  so  under  the  arm,  the 
elbow  and  the  fore-arm  to  the  axilla  of  the  sound  side ;  from 
this  point,  repeat  the  same  course  until  several  turns  have 
been  made  in  doloires  opening  towards  the  point  of  the 
shoulder.  Having  reached  the  axilla  after  the  fourth  or  fifth 
fold,  continue  the  roller  in  circular  sweeps  passing  horizontally 
around  the  back,  the  axilla  of  the  injured  side,  the  arm,  elbow 
and  fore-arm,  and  thus  alternate  the  oblique  and  horizontal 
turns  until  the  roller  is  exhausted.  In  order  to  make  the 
folds  secure,  insert  pins  at  the  different  points  of  crossing,  or 
cover  the  whole  with  the  starch  or  dextrine  solution.  A 

FIG.  46. 


136 


FRACTURES  OF  THE  SCAPULA. 


graduated  compress  applied  upon  the  coracoid  process,  before 
crossing  it  with  the  roller,  will  adapt  this  bandage  more  per- 
fectly to  this  particular  fracture  (fig.  46). 

3.  Of  the  acromion  process  and  the  neck  of  the  scapula. 
When  the  neck  of  the  bone  is  separated  from  the  body,  it 
is  drawn  downwards  by  the  weight  of  the  arm,  and  the  course 
of  treatment  is  at  once  rendered  manifest,  viz.,  to  apply  such 
a  dressing  as  shall  restore  the  bone  to  its  natural  situation 
and  preserve  its  apposition  with  the  main  fragment.  A  pad 
should  be  placed  in  the  axilla  against  the  head  of  the  humerus 
and  firmly  supported,  while  the  shoulder  is  raised  and  the 
arm  maintained  in  repose  upon  the  breast,  with  the  fore-arm 
flexed.  Fox's  apparatus  for  fractures  of  the  clavicle  fulfils  all 
the  indications  very  perfectly.  (See  fracture  of  the  clavicle.) 
When  the  acromion  process  is  broken,  the  weight  of  the 
arm,  as  in  the  other  case,  draws  the  fragment  from  its  natural 
position,  and  the  same  kind  of  treatment  is  indicated,  with 
the  addition  of  a  certain  degree  of  compression  upon  the  pro- 
cess itself.  The  apparatus  of  Dr.  Fox  is  applicable  to  this 
injury,  also — with  a  figure-8  bandage  applied  to  act  upon  a 
compress  placed  upon  the  acromion  process  (see  crossed  ban- 
dage of  shoulder  and  axilla) ;  or  the  mode  of  dressing  recom- 
mended by  Mr.  Lonsdale  will  fulfil  the  indications  very  ele- 
gantly. The  process  may 
be  steadied  by  the  spica 
bandage,  which  is  to  be 
applied  over  the  shoulder 
and  then  under  the  axilla 
of  the  affected  side,  &c., 
&c.,  until  the  roller  is 
nearly  exhausted.  The 
last  part  of  the  bandage 
may  be  made  to  cross  the 
shoulder,  to  descend  in 
front  and  pass  under  the 
elbow' and  lower  part  of 
the  fore-arm,  by  which 
means  any  degree  of  pres- 
sure can  be  made  upwards 
with  the  head  of  the  hu- 
merus, by  simply  shortening  that  portion  of  the  roller  which 


FIG.  47. 


FRACTURES  OF  THE  SCAPULA.       1ST 

passes  under  the  elbow.  The  wood-cut  (fig.  47)  represents 
this  bandage  applied.  (Lonsdale,  p.  202,  3.)  It  will  be  seen 
at  once  that,  by  regulating  the  length  of  the  sling  on  which 
the  elbow  reposes,  and  allowing  the  wrist  and  hand  to  droop 
more,  or  less,  as  may  be  required  in  each  particular  case,  the 
degree  of  pressure  upwards  against  the  acromion  process 
may  be  much  modified.  This  bandage  of  Mr.  Lonsdale 
is  open  to  the  objection,  that  it  does  not  sufficiently  confine 
the  arm. 

The  bandage  of  Yelpeau,  above  described,  will  also  answer 
very  well  for  the  treatment  of  this  fracture.  (Fig.  46.) 

After  fractures  of  the  scapula,  generally,  the  parts  should 
be  kept  at  rest  in  a  secure  apparatus  for  six  or  eight  weeks, 
and  when  the  neck  of  the  bone  is  detached  from  the  body,  a 
longer  time  is  required  to  complete  the  union ;  Sir  A.  Cooper 
fixes  it  at  from  ten  to  twelve  weeks.  But  as  soon  as  the 
fragments  have  become  so  far  united,  as  that  there  is  no  per- 
ceptible motion  between  them,  upon  careful  and  gentle  hand- 
ling, passive  motion  should  be  resorted  to  :  this  is  particularly 
important  in  fracture  of  the  neck  of  the  scapula,  for,  if  the 
shoulder-joint  is  allowed  to  remain  perfectly  motionless 
during  the  ten  or  twelve  weeks  which  are  requisite  for  entire 
solidification  of  the  fracture,  the  head  of  the  humerus  will  be 
found  to  have  become  so  firmly  fixed  in  its  socket,  that  ano- 
ther series  of  weeks  will  be  required  to  restore  to  the  joint  its 
ease  of  motion. 

In  compound  fractures  of  the  scapula  and  clavicle,  an  object 
of  primary  importance  is,  as  in  all  other  compound  fractures, 
to  convert  the  injury  as  speedily  as  possible  into  a  case  of 
simple  fracture,  by  inducing  closure  of  the  wound  by  the  first 
intention.  The  mode  of  effecting  this  is  the  same  as  in  other 
similar  injuries :  by  approximating  the  edges  of  the  wound, 
and  retaining  them  in  contact  by  adhesive  plaster.  If  the 
surgeon  fails  of  accomplishing  this  purpose,  and  suppura- 
tion ensues,  the  poultice,  or  the  water-dressing,  must  bo 
substituted. 


12* 


CHAPTER  IV. 

ON   THE   APPARATUS   AND   DRESSINGS  FOR  FRACTURES   OF  THE 
BONES    OF   THE    UPPER   EXTREMITY. 

SECTION    I. 
FOR    FRACTURES    OF    THE    HUMERUS. 

IT  is  in  fractures  of  the  long  bones  of  the  extremities,  that 
displacements  are  most  frequent  and  most  varied  in  direction  ; 
for  these  bones  are  acted  upon  at  different  points  of  their 
surface  by  numerous  muscles,  having  contractile  fibres,  vary- 
ing in  their  lengths  and  in  their  directions  of  contraction. 
Hence,  in  a  measure,  the  great  numbers  of  apparatus  which 
have  been  contrived  for  the  treatment  of  these  injuries. 

The  humerus  may  be  broken  in  its  shaft,  or  at  the  eondy- 
loid,  or  scapular  extremity ;  the  first  is  the  most  frequent  seat 
of  fracture. 

1.  Fracture  at  the  shaft  of  the  bone  may  occur  either 
above,  or  below,  the  line  of  insertion  of  the  deltoid  muscle ; 
in  either  case,  there  will  be  displacement  of  the  portions  of 
the  bone,  excepting  in  rare  instances,  when  the  fracture  is 
strictly  transverse,  and  has  been  caused  by  a  force  insufficient 
to  throw  the  lower  fragment  from  the  axis  of  the  upper ;  and 
even  if  the  arm  be  not  shortened,  it  will  probably  be  some- 
what curved  by  the  action  of  the  muscles,  which  operate  from 
above  the  fracture  upon  the  lower  fragment. 

When  the  fibres  of  the  bone  have  been  ruptured  above  the 
insertion  of  the  deltoid,  the  upper  segment  will  be  drawn  in- 
wards towards  the  chest,  by  the  action  of  the  pectoralis 
major,  chiefly,  while  the  lower  fragment  will  be  drawn  up- 
wards and  outwards  by  the  combined  action  of  the  deltoid, 
and  the  triceps  and  biceps  muscles. 

If  the  fracture  has  occurred  below  the  attachment  of  the 
deltoid,  this  muscle  will  raise  the  upper  fragment  outwards, 
while  the  lower  portion  will  be  drawn  a  little  upwards,  and 
inwards  also  with  reference  to  the  assumed  position  of  the 

(138) 


FRACTURES    OF    THE    HUMERUS.  139 

upper  fragment,  by  the  contraction  of  the  muscles  which 
pass  from  the  scapula  to  the  lower  part  of  the  arm  and  the 
elbow. 

Whether  the  shaft  of  the  bone  has  been  broken  above,  or 
below,  the  point  under  consideration,  the  indications  of  treat- 
ment will  be  the  same,  viz. :  to  restore  the  limb  to  its  proper 
length  and  axis,  if  these  have  been  altered,  and  to  keep  the 
parts  at  rest.  This  object  will  be  best  accomplished  by  the 
following  plan,  which  is  adapted  to  both  of  the  supposed 
cases  :  —  Envelope  the  arm,  from  the  fingers  to  the  axilla,  by 
a  roller  applied  so  as  to  make  uniform  and  moderate  pressure 
upon  the  muscles ;  then,  the  arm  being  carefully  supported 
by  an  assistant,  take  four  splints  made  of  thin  wood,  —  (the 
sides  of  a  cigar-box  will  answer  perfectly  well,) — and  evenly 
padded  with  cotton,  and  apply  them  separately  in  front,  and 
at  the  sides  of,  and  behind  the  arm,  and  secure  them  in  these 
situations  by  a  roller.  The  splint  for  the  anterior  face  of 
the  arm  should  extend  from  the  head  of  the  bone  to  just 
above  the  bend  of  the  elbow ;  the  others  from  the  same  point 
to  the  extremity  of  the  humerus,  the  projections  of  the  con- 
dyles  being  carefully  protected  from  too  much  pressure. 
After  the  splints  have  been  bandaged  to  the  arm,  this  should 
be  brought  a  little  forwards,  so  that  the  fore-arm  resting  in  a 
sling,  may  be  supported  on  the  front  of  the  chest,  in  the 
flexed  position.  In  order  to  give  greater  security  to  the  arm, 
a  few  circular  turns  of  the  roller  should  confine  it  to  the 
chest. 

If,  from  any  cause,  it  be  desirable  to  dispense  with  the 
inner  splint,  the  fracture  may  be  treated  equally  well,  by  se- 
curing a  wedge-shaped  pad  in  the  axilla,  the  thick  end  down- 
wards, so  as  to  present  a  perpendicular  surface  from  the 
glenoid  cavity  to  the  extremity  of  the  humerus,  upon  which  the 
latter  may  rest :  then,  having  applied  the  roller,  and  the  three 
other  splints,  as  directed  above,  place  the  inner  surface  of  the 
arm  against  the  pad,  and  bandage  it  to  the  chest  by  circular 
sweeps  of  the  roller :  the  fore-arm  should  be  supported  in  a 
sling,  as  above  directed. 

Another  modification  of  the  same  plan  consists  in  substi- 
tuting for  the  short  splint,  which  is  applied  upon  the  inner 
aspect,  or  on  the  front  of  the  arm,  a  rectangular  splint,  made 
to  extend  all  along  the  inner  or  the  anterior  face  of  the  limb, 


140 


FRACTURES    OF    THE    HUMERUS. 


FIG.  48. 


from  the  head  of  the  huraerus  to  the  ends  of  the  fingers. 
Thus,  all  motion  of  the  fore-arm  will  be  prevented. 

There  is  rarely  much  disposition  to  great  shortening  of  the 
arm,  in  fracture  of  the  shaft  of  the  humerus ;  so  that,  in  the 
vast  majority  of  cases  of  this  accident,  the  lateral  pressure 
effected  in  the  manner  just  described,  is 
amply  sufficient  to  retain  the  fragments  in 
apposition.  Mr.  Lonsdale,  however,  has 
met  with  several  cases  in  which  he  found  it 
necessary  to  keep  up  permanent  extension 
and  counter-extension;  and,  to  accomplish 
this  object,  he  invented  a  splint  which  he 
thus  describes  : — "  It  consists  of  a  thin  bar 
of  iron,  about  an  inch  and  a  half  wide,  and 
long  enough  to  extend  from  the  axilla  to  the 
elbow,  —  marked  B  in  the  wood-cut.  (See 
fig.  48.)  The  lower  end  of  the  bar  curves 
upwards  underneath  the  elbow,  so  as  to 
allow  of  this  part  of  the  limb  fitting  into  it, 
at  C.  This  curve  terminates  in  a  hook,  E, 
for  the  attachment  of  a  bandage ;  and  on 
the  splint  opposite  to  this  hook  is  a  small 
bar,  placed  across  the  perpendicular,  also 
for  the  attachment  of  a  bandage.  To  the 
upper  extremity  of  the  splint  a  crutch  is  adapted,  A,  which 
fits  underneath  the  axilla,  and  is  movable  up  and  down,  being 
confined  at  pleasure  by  means  of  a  small  screw,  placed  at  the 
side  of  the  vertical  bar."  In  applying  it,  the  crutch-like  ex- 
tremity is  secured  in  the  axilla,  the  upper  part  of  the  arm  fit- 
ting into  it,  and  the  elbow  is  confined  in  the  inferior  curve  by 
means  of  a  bandage  passing  around  the  limb  at  the  elbow, 
and  having  attachments  to  the  splint  at  the  hook,  and  at  the 
transverse  bar,  as  already  indicated.  The  whole  arm  should 
be  enveloped  by  a  roller,  and  one  or  two  lath  splints  applied 
on  the  exterior,  or  anterior,  surface  of  the  limb ;  the  fore- 
arm should  be  supported  in  a  sling.  (Lonsdale,  op.  cit., 
p.  173,  &c.) 

It  is  very  conceivable  that  a  splint  of  this  kind  would  be 
of  much  use  in  cases  of  compound  fracture  of  the  humerus, 
where  the  limb  cannot  be  wrapped  in  splints  and  bandages  in 
the  usual  manner,  and  where  some  degree  of  compression 


FRACTURES    OF    THE    HUMERUS.  141 

and  support  is  required  to  keep  the  fragments,  in  any  mea- 
sure, in  place.  If  employed  in  such  cases,  the  straight 
splints  and  the  enveloping  of  the  limb  should  be  omitted ; 
but  the  arm  should  be  lightly  secured  to  the  splint  at  the 
axilla,  and  also  at  the  elbow,  while  another  roller,  or  a  band- 
age of  Scultetus,  shall  at  once  serve  to  retain  the  fragments 
in  tolerable  apposition,  to  confine  upon  the  seat  of  fracture 
any  proper  application,  and  to  support  the  whole  against  the 
side  of  the  splint.  A  little  ingenuity  on  the  part  of  the  sur- 
geon will  enable  him  to  form  a  splint  of  wood,  after  the  pat- 
tern of  Mr.  Lonsdale,  which  will  answer  the  purpose  equally 
well.  But  compound  fractures  of  the  humerus  may  be 
treated  very  well,  in  most  instances,  by  placing  the  arm  in  a 
curved  splint  made  of  sheet  tin,  or  of  pasteboard,  moulded 
to  an  arm  of  somewhat  larger  diameter  than  that  of  the 
patient,  and  well  padded ;  the  limb  should  be  secured  to  the 
splint,  above  and  below  the  seat  of  fracture,  by  means  of  a 
roller  carefully  applied,  and  leaving  the  wound  exposed ; 
then,  by  a  bandage  of  Scultetus,  a  suitable  dressing  should 
be  retained  upon  the  wound,  and  this  part  of  the  arm  pressed 
gently  against  the  splint :  the  fore-arm  must  be  supported  as 
usual. 

After  a  certain  time,  when  the  fracture,  whether  it  may 
have  been  simple  or  compound,  has  become  tolerably  firm,  two 
curved  splints,  made  of  pasteboard,  may  be  conveniently  sub- 
stituted for  the  ordinary  lath  splints ;  or  the  immovable  appa- 
ratus may  be  used.  The  usual  time  required  to  insure  the 
consolidation  of  this  form  of  fracture  is  about  six  weeks. 

2.  Fractures  of  the  upper  extremity  of  the  humerus. 

The  humerus  may  be  broken  either  at  its  surgical  neck, 
that  portion  of  the  bone,  namely,  which  is  included  between 
the  margin  of  the  articular  head  and  the  point  of  the  inser- 
tion of  the  pectoralis  major  muscle,  or  at  its  anatomical  neck, 
a  narrow  rim  of  bone  separating  the  curved  head  from  the 
tubercles.  Fracture  at  the  surgical  neck  is  much  the  most 
common. 

When  the  bone  is  broken  at  the  anatomical  neck,  there  is 
often  little  or  no  displacement,  the  fractured  surfaces  being 
so  broad  at  this  point.  But  there  is  generally  some  derange- 
ment of  the  axis  of  the  limb,  the  lower  fragment  being  drawn 


142  FRACTURES    OF    THE    HUMERTTS. 

inwards  by  the  pectoralis  major,  and  upwards  by  the  muscles 
which  pass  from  the  scapula  to  the  lower  part  of  the  arm. 

The  displacement  is  greater  when  the  fracture  occurs  at 
the  surgical  neck,  for  the  upper  fragment  will  be  rotated  out- 
wards by  the  supra  and  infra-spinatus  muscles,  while  the 
lower  portion  is  acted  upon  as  before  mentioned. 

In  both  cases  the  same  indication  is  to  be  fulfilled,  and  it 
will  be  readily  accomplished  by  confining  a  pad  in  the  axilla, 
•with  the  thick  end  downwards,  so  as  to  present  a  plane,  per- 
pendicular surface  to  the  shaft  of  the  limb ;  then  apply  a 
roller  from  the  fingers  up  to  the  head  of  the  arm,  and  having 
reduced  the  fragments  to  apposition,  place  a  compress  over 
the  seat  of  fracture  on  the  outer  face  of  the  arm,  and  upon 
this  a  curved  pasteboard  splint  extending  from  the  acromion 
process  to  the  outer  condyle ;  support  the  fore-arm  in  a  sling, 
and  confine  the  arm  to  the  side  of  the  chest  by  circular  folds 
of  a  roller  passing  from  the  elbow  to  the  shoulder.  Or  an 
angular  splint  may  also  be  bandaged  to  the  inner  face  of  the 
arm  and  fore-arm,  the  hand  being  semi-pronated,  —  and  the 
pad  used  as  above. 

The  limb  should  be  kept  perfectly  at  rest  for  six  or  eight 
weeks,  excepting  that  after  the  fracture  has  become  sufficiently 
firm,  passive  motion  should  be  gently  made,  every  day  or  two, 
as  the  bandages  are  freshly  applied. 

3.  Fractures  of  the  condyloid  extremity  of  the  humerus. 

FIG.  49. 


The  shaft  of  the  bone  may  be  broken  just  above  the  con- 
dyles,  as  is  represented  in  the  annexed  drawing  (fig.  49), 
taken  from  Sir  A.  Cooper's  Treatise  on  Dislocations  and 


FRACTURES    OF    THE    HUMERUS.  143 

Fractures,  p.  401,  American  edition;  or  the  fracture  may 
implicate  the  condyles  themselves,  "extending  in  three  direc- 
tions :  First,  the  extremity  only  of  either  condyle  may  be 
broken  off,  as  represented  at  A,  in  the  wood-cut  (see  fig.  50). 
Secondly,  the  fracture  may  include  a  large  portion  of  one 
condyle  only,  but  extend  directly  into  the  joint,  as  at  B. 


FIG.  50. 


Thirdly,  both  the  condyles  may  be  severed  from  each  other, 
and  from  the  shaft  of  the  bone,  as  well  as  shown  at  C." 
(Lonsdale,  p.  181.) 

When  the  solution  of  continuity  has  involved  the  shaft  of 
the  bone,  immediately  above  the  condyles,  the  lower  fragment 
will  be  drawn  upwards  and  behind  the  humerus  by  the  contrac- 
tion of  the  triceps  muscle,  dragging  with  it,  of  course,  the  fore- 
arm, as  represented  in  fig.  49, — or  it  may  be  drawn  up  on  the 
front  of  the  arm,  depending,  in  a  great  measure,  upon  the  di- 
rection of  the  force  which  caused  the  fracture.  The  same  sort 
of  displacement  may  ensue  when  the  whole  of  the  internal 
condyle  is  split  off,  as  shown  at  B,  fig.  50,  since  the  ulna  will 
be  acted  upon  by  the  same  muscles  as  in  the  other  case ;  but 
there  need  not  be  this  separation  of  the  fragments,  unless  the 
violence  has  been  sufficient  to  rupture  the  external  lateral  and 
the  capsular  ligaments.  So  also  when  the  external  condyle 
alone  is  severed  from  its  bony  connexions,  the  ligaments  may 
still  retain  it  in  place,  if  they  have  escaped  rupture ;  and  dis- 
placement is  still  less  necessary  if  the  point  merely  of  the  in- 
ternal condyle  be  broken  off,  as  at  A,  fig.  50.  But  when,  as 
at  C,  the  condyles  are  not  only  separated  from  each  other  but 
from  the  shaft  of  the  bone  likewise,  shortening  of  the  arm  is 
an  almost  certain  result,  from  the  operation  of  the  same  causes 
as  when  the  shaft  of  the  bone  has  been  fractured  above  the 
epiphysis.  The  treatment  in  every  case  is  pretty  much  the 
same,  although  the  degree  of  success  which  attends  it  will  vary 


144 


FRACTURES    OF    THE    HUMERUS. 


very  much,  agreeably  to  the  extent  to  which  the  joint  may 
have  been  implicated. 

The  method  recommended  by  Sir  Astley  Cooper,  when  the 
shaft  of  the  bone  has  been  broken  as  above  described, — and, 
with  some  modifications  and  additions,  it  is  applicable  to  the 
other  cases, — consists  "in  bending  the  arm,  and  drawing  it 
forwards  to  effect  replacement;  then  a  roller  should  be  applied 
while  it  is  in  the  bent  position.  The  best  splint  for  it  is  one 
formed  at  right-angle,  the  upper  portion  of  which  should  be 
placed  behind  the  arm,  and  the  lower  portion  under  the  fore- 
arm ;  a  splint  must  also  be  placed  upon  the  anterior  face  of 
the  upper  arm,  and  both  should  be  confined  by  straps :  evapo- 
rating lotions  should  be  used,  and  the  fore-arm  be  kept  in  the 
flexed  position  and  supported  by  a  sling.  In  a  fortnight,  if 
the  patient  be  young,  passive  motion  may  be  gently  begun  to 
prevent  the  occurrence  of  anchylosis ;  and  in  the  adult,  at  the 
end  of  three  weeks,  a  similar  treatment  should  be  pursued. 
But  even  after  the  most  careful  and  judicious  means  which 
can  be  adopted,  there  is  sometimes  considerable  loss  of  motion  ; 

and  when  the  accident 
has  not  been  understood, 
or  has  been  carelessly 
treated,  the  deformity 
and  loss  of  motion  be- 
come very  considera- 
ble." (See  fig.  51,  in 
which,  however,  the 
roller  should  have  been 
represented  as  applied 
to  the  fore-arm  and  el- 
bow.) 

The  mode  of  treat- 
ment generally  adopted 
in  this  city  consists  in 
enveloping  the  limb,  from  the  fingers  to  above  the  line 
of  fracture,  in  a  roller,  the  fore-arm  being  flexed  and  the  frag- 
ments having  been  restored  to  apposition ;  then  a  flat,  or 
slightly  grooved,  rectangular  splint  is  applied  upon  the  ante- 
rior face  of  the  arm,  fore-arm,  and  hand — or  upon  their  inner 
aspect,  the  hand  being  semi-pronated,  —  and  secured  thus  by 
means  of  a  roller,  a  compress  having  been  placed  upon  the 


FIG.  51. 


FRACTURES    OF    THE    HUMERUS.  145 

point  of  the  internal  condyle  if  this  has  been  severed ;  the 
fore-arm  should  then  be  supported  upon  the  chest  by  a  sling. 
But  if  the  fracture  has  involved  the  articular  face  of  one  or 
both  condyles,  it  is  advisable,  in  addition  to  the  splint,  to 
give  increased  support  to  the  posterior  face  of  the  elbow. 
For  this  purpose  a  piece  of  pasteboard  should  be  taken,  suffi- 
ciently long  to  extend  from  three  to  four  inches  above  the 
elbow,  and  for  the  same  distance  below  it,  and  wide  enough 
to  envelope  the  joint  laterally;  this  should  be  notched  at 
different  points,  so  that  after  it  has  been  softened  in  hot 
water,  it  may  be  made  to  fit  the  elbow.  Then,  the  arm 
having  been  bandaged,  as  before  directed,  and  the  anterior 
splint  applied,  this  cap  should  be  placed  upon  the  posterior 
face  of  the  elbow — care  being  taken  to  protect  the  bony  pro- 
jections from  great  pressure — and  confined  by  the  roller  which 
secures  the  other  splint.  At  the  end  of  ten  days  or  two  weeks, 
or  earlier  if  all  pain  has  ceased  and  if  the  bone  has  become 
sufficiently  firm,  passive  motion  should  be  resorted  to  from 
day  to  day,  the  condyles  being  supported  by  the  hand,  and 
the  angle  of  the  anterior  splint  changed.  After  the  lapse  of 
eight  or  ten  weeks,  the  confinement  may  be  omitted.  It 
should  be  borne  in  mind  that  daily  motion  of  thet  joint  is  of 
the  greatest  importance  in  the  treatment  of  fractures  about 
the  elbow,  but  it  should  be  practised  cautiously  and  with  the 
limitations  above  mentioned. 

When  the  fracture  is  compound,  the  same  indications  are 
still  to  be  accomplished  as  when  it  is  simple,  and  the  same 
plan  is  to  be  pursued.  The  splints  must  be  so  contrived, 
however,  as  to  allow  of  frequent  inspection  and  dressing  of 
the  wound,  without  requiring  the  removal  of  the  whole  ap- 
paratus. This  may  be  effected  by  using  splints  of  binders' 
board  previously  softened  and  moulded  to  the  shape  of  the 
part,  and  large  enough  to  give  easy  support  to  the  fractured 
limb ;  an  aperture  should  be  made  in  the  splint  opposite  the 
wound,  sufficiently  large  to  permit  of  free  examination  of  the 
injury  to  the  soft  parts.  The  limb  should  be  softly  cushioned 
in  the  splints,  and  secured  to  them  above  and  below  the 
wound,  while  the  particular  dressing  required  for  the  latter 
may  be  laid  over  the  aperture  corresponding  with  it  in 
situation,  and  confined  by  the  bandage  of  Scultetus.  Or, 
when  the  wound  is  on  the  anterior  face  of  the  arm,  the  fore- 
13 


146 


FRACTURES    OF    THE    HUME  R  US. 


arm  may  be  enveloped  in  a  roller,  as  in  the  other  cases,  and 
a  "bandage  of  Scultetus  be  applied  immediately  to  the  upper- 
arm,  over  the  wound,  or  upon  the  dressing  which  covers  it, 
while  a  curved  angular  splint  supports  the  posterior  aspect  of 
the  whole  limb.  The  fore-arm  should  be  sustained  by  a  sling 
in  either  case. 

Mr.  Mayo  contrived  a  very  simple  splint  for  the  treatment 
of  a  case  of  bad  compound  fracture  of  the  condyles,  by  which 
the  requisite  support  was  given  to  the  bones,  and  the  wound 
still  allowed  to  discharge  freely,  and  sufficiently  exposed  to 
be  dressed  without  much  disturbance  of  the  limb.  As  such 
instances  sometimes  occur,  it  is  well  to  have  an  acquaintance 
with  the  mode  employed  to  treat  them,  as  adopted  by  so  high 
an  authority  as  Mr.  Mayo.  The  apparatus  "  consists  of  two 
splints  joined  together  by  two  small  bars,  so  as  to  leave  a 
space  between  them  for  the  elbow  to  fit  into.  One  of  the 
splints,  B,  in  the  wood-cut,  (see  fig.  52,)  is  made  for  the  back 
part  of  the  arm  to  lie  upon,  while  the  other,  C,  is  for  the 
forearm ;  the  second  splint  terminates  in  a  horizontal  portion, 
D,  for  the  hand  to  rest  upon ;  the  intervening  space,  A,  is 
formed  by  the  two  lateral  bars,  which  are  slightly  curved  out- 
wards, to  prevent  pressure  upon  the  joint."  This  splint 
should  be  padded,  and  the  limb  secured  to  it  above  and  below 
the  seat  of  injury,  by  an  ordinary  roller,  while  opposite  the 
wound  itself  the  bandage  of  Scultetus  should  be  used  for  the 
same  purpose,  and  also  to  retain  suitable  dressings  upon  the 
part.  (Lonsdale,  p.  189.) 

FIG.  52. 


With  regard  to  the  frequency  with  which  the  apparatus 
should  be  removed,  and  the  fracture  dressed,  in  cases  of  this 
injury  generally,  only  conditional  directions  can  be  given. 
If,  in  a  simple  fracture,  there  be  no  unpleasant  symptom  or 


FRACTURES    OF    THE    HUMERUS.  147 

appearance  after  the  limb  is  first  dressed,  the  bandage  need 
not  be  removed  for  two  or  three  days,  and  this  quiescence  of 
the  limb  is  attended  with  many  advantages,  especially  when 
the  fracture  has  involved  the  joint  directly  or  indirectly.  But 
if  the  patient  should  complain  of  pain  in  the  injured  part,  the 
envelopes  should  be  removed  at  least  once  daily,  and  the 
injury  examined ;  unless  this  attention  is  practised,  sloughing 
of  the  soft  parts,  or  troublesome  excoriations,  will  often  occur. 
The  first  application  of  the  roller  and  splints  should  be  made 
carefully,  so  as  to  exert  only  a  moderate  degree  of  pressure, 
and  to  allow  of  the  swelling  which  follows  upon  almost  every 
fracture ;  and  the  compression  made  around  the  lower  part 
of  the  limb  should  be  proportioned  to  that  upon  the  upper, 
else  the  soft  parts  below  will  become  swollen  and  painful,  and 
finally  gangrene  may  ensue. 

In  the  wards  of  the  Pennsylvania  Hospital,  in  this  city,  it 
is  rare  that  blood  is  taken  from  about  the  joint  in  case  of 
fracture ;  but  the  fragments  are  placed  in  apposition  as  speed- 
ily as  possible,  and  confined,  as  above  advised,  —  perfect  rest 
being  considered  a  sufficiently  powerful  antiphlogistic  remedy ; 
frequently,  indeed,  this  is  aided  by  the  influence  of  evapo- 
rating or  sedative  lotions,  as  diluted  spirits,  or  lead-water. 

In  compound  fractures,  the  best  local  application  to  the 
seat  of  injury,  after  the  means  hereinbefore  advised  for  the 
promotion  of  direct  closure  of  the  wound  have  failed,  is  a 
poultice,  or  the  water-dressing:  if  the  former  be  used,  it 
should  be  changed  at  least  twice  daily,  and  as  much  oftener 
as  may  be  required  by  the  amount  or  nature  of  the  discharge  : 
as  the  wound  contracts,  and  the  suppuration  becomes  very 
scanty,  some  stimulating  lotion,  or  cerate,  may  be  advanta- 
geously substituted.  Passive  motion  should  be  resorted  to, 
and  diligently  practised,  as  soon  as  the  condition  of  the  parts, 
internal  and  external,  will  allow;  this  injunction  is  of  the 
utmost  consequence-  after  compound  fractures  near  to,  or 
involving,  the  joint,  because  it  cannot  be  resorted  to  so  early 
as  in  simple  fractures,  owing  to  the  greater  length  of  time 
requisite  for  the  union  of  the  fragments,  and  because  also  the 
joint  has  suffered  more,  in  most  cases,  than  in  the  other  class 
of  injury.  In  both,  the  rigidity  of  the  parts  may  be  lessened 
by  frequently  soaking  the  joint  in  warm  water. 

Comminuted  fractures  of  the  humerus  require  no  different 


148  FRACTURES    OF    THE 

treatment,  as  a  general  rule,  from  the  simple,  excepting  rather 
nicer  manipulation  in  reducing  them,  and  in  the  application 
of  compresses,  and  a  somewhat  longer  confinement. 


i  SECTION  II. 

FOR  FRACTURES  OF  THE  BONES  OF  THE  FORE-ARM. 

The  complicated  movements  of  the  fore-arm,  and  the  varied 
action  of  the  numerous  muscles  necessary  to  effect  them, 
occasion,  when  one  or  both  bones  are  broken,  many  forms  of 
displacement  of  the  fragments.  To  remedy  these,  so  as  to 
preserve  unimpaired  the  mobility  of  the  limb,  it  becomes 
necessary  for  the  surgeon  to  resort  to  a  variety  of  expedients, 
•which  it  is  the  object  of  this  section  to  set  forth. 

In  fractures  of  the  fore-arm,  whether  of  one  or  both  bones, 
there  is  one  common  indication  to  be  fulfilled,  excepting  when 
the  fracture  has  occurred  very  near  to  the  extremities  of  the 
bones ; — this  is  to  preserve  the  interosseous  space,  which  is 
almost  always  encroached  upon  by  the  fragments. 

1.  For  fractures  of  both  bones. 

The  displacement  in  these  cases  may  be  in  the  diameter  or 
in  the  length  of  the  fore-arm,  or  in  both  directions.  Gene- 
rally, there  is  not  much  difficulty  in  retaining  the  fragments 
in  proper  apposition  after  reduction.  The  mode  of  accom- 
plishing it,  as  it  is  commonly  practised,  consists  in  applying 
upon  the  anterior  face  of  the  fore-arm,  a  long  compress  which 
fits  over  the  interosseous  space,  and  then  placing  a  straight, 
padded  splint,  sufficiently  long  to  extend  from  the  elbow  to 
the  ends  of  the  fingers,  upon  the  front,  and  another  of  the 
same  length  upon  the  back  of  the  fore-arm,  and  securing  them 
by  circular  and  reverse  turns  of  the  roller.  The  width  of  the 
splints  should  be  greater  than  that  of  the  arm,  so  that  the 
convolutions  of  the  bandage  shall  not  press  the  two  bones 
towards  each  other. 

Sometimes  considerable  difficulty  is  experienced  in  coun- 
teracting a  lateral  angular  displacement :  but  generally  this 
may  be  overcome  by  applying  a  compress  of  suitable  thick- 
ness over  the  point  of  deformity,  at  the  side  of  the  fore-arm, 


BONES    OF    THE    FORE-ARM.  149 

and  by  removing  also,  if  necessary,  the  compression  exercised 
upon  the  interosseous  space  at  this  point. 

After  the  fore-arm  is  thus  suitably  dressed,  it  is  placed  in 
a  position  midway  between  proriation  and  supination,  —  the 
palm  of  the  hand  towards  the*  chest,  the  thumb,  which  is  left 
uncovered,  presenting  upwards, — and  supported  in  a  sling  in 
the  flexed  position. 

Both  bones  are  not  commonly  broken  at  the  same  level, 
but  this  circumstance  does  not  alter  the  general  mode  of 
treatment. 

Mr.  Lonsdale  objects  to  this  mode  of  treatment,  on  the 
ground  that  the  position  in  which  the  fore-arm  is  placed, — 
that  of  semi-pronation,  —  is  not  the  one  which  is  most  calcu- 
lated to  insure  perfection  in  the  motions  of  the  limb.  The 
muscles  which  tend  to  throw  the  upper  fragment  of  the  radius 
in  supination,  are  the  supinator  radii  brevis  and  the  biceps 
flexor  cubiti,  and,  agreeably  to  Mr.  Lonsdale's  argument, 
these  combined  exert  more  power  than  the  pronator  muscle 
which  operates  upon  this  fragment, — the  pronator  radii  teres  ; 
hence  the  upper  portion  of  the  radius  is  placed  in  a  much 
more  supine  position  than  the  lower,  if  the  palm  of  the  hand 
is  turned  towards  the  chest,  with  the  thumb  presenting 
directly  upwards ;  and  if  union  of  the  two  fragments  of  the 
radius  takes  place  in  this  faulty  relative  position,  the  extent 
to  which  pronation  and  supination  can  be  effected  will  be 
impaired,  as  is  not  unfrequently  noticed. 

To  obviate  this  difficulty,  Mr.  Lonsdale  recommends  that 
the  hand  be  placed  supine,  and  that  two  straight  splints  be 
bandaged  to  the  fore-arm,  precisely  as  in  the  ordinary  plan  of 
treatment ;  then  the  fore-arm  should  be  supported  in  a  sling, 
the  elbow  approximated  to  the  chest,  and  the  hand  projecting 
before  the  body. 

The  splints  should  be  retained  for  five  or  six  weeks  in  frac- 
ture occurring  to  an  adult,  and  for  four  or  five  weeks  when  a 
child  is  thus  injured. 

In  compound  fractures  of  the  fore-arm,  only  one  splint  can 
be  used,  as  a  general  rule,  with  advantage.  Tolerably  good 
apposition  of  the  fragments  can  be  effected  with  a  single  splint, 
by  a  judicious  arrangement  of  compresses  and  a  roller,  or  ban- 
dage of  Scultetus ;  pressure  upon  the  wound  itself  should  be 


150 


FBACTUKES    OF    THE 


FIG.  53. 


avoided,  but,  on  the  contrary,  every  facility  should  be  offered 
to  the  escape  of  the  pus. 

The  "  Ante-Brachial  Hyponarthecia,"  of  Sauter  and  May- 
or is  quite  well  adapted  to  the  treatment  of  compound  frac- 
tures of  the  fore-arm,  of  one  or  both  bones.  It  is  thus  described 
by  M.  Cutler : 

"COMPOSITION.  —  A  board  of  convenient  width,  a  little 
longer  than  the  fore-arm  and  hand,  a  cushion,  a  cord  for  arc- 
loops,  and  three  cravats. 

"  APPLICATION. — The  fracture  being  reduced,  the  fore-arm 

is  placed  upon  the  cushioned 
board,  #,  t>  (fig.  53)>  which  is  im- 
mediately suspended  from  the  pa- 
tient's neck  by  means  of  the  arc- 
loops,  e  e, — the  ring  /,  and  the 
cervical  cravat,  g.  The  second 
cravat,  £,  is  now  passed  under 
the  wrist,  and  crossed  upon  the 
back  of  the  hand,  the  tails  being 
then  made  to  embrace  the  cush- 
ioned board,  and  knotted  at  its 
anterior  border,  as  represented 
at  h.  The  third  cravat  is  made 
to  pass  around  the  apparatus  at 
its  upper  part,  so  as  to  confine  the 

corresponding  portion  of  the  fore-arm,  and  is  then  knotted  as 
the  other.  If  it  be  necessary  to  counteract  any  lateral  dis- 
placement, a  fourth  cravat  may  be  made  ufee  of,  to  serve  as  a 
'  traction  ligature,'  which  will  of  course  be  knotted  at  the  in- 
ner margin  of  the  suspension-board."  This  apparatus  leaves 
the  fore-arm  exposed  to  constant  inspection,  and  suitable  dress- 
ings can  be  applied  to  the  wound  without  deranging  the  limb  ; 
if  the  discharge  be  very  profuse,  bran  may  be  conveniently 
placed  upon  the  board  and  around  the  arm  to  absorb  the  pus. 
When  the  patient  lies  down,  the  apparatus  should  be  detached 
from  the  cervical  cravat  and  placed  upon  a  pillow,  or  suspended 
from  the  top  of  the  bed,  or  from  the  ceiling.  If  it  be  deemed 
expedient,  for  greater  security,  to  confine  the  whole  limb,  it 
can  be  very  easily  accomplished  by  selecting  a  longer  board 
and  cushion,  extending  from  the  axilla  to  the  extremities  of 


BONES    OF    THE    FORE-ARM.  151 

the  fingers,  and  employing  a  sufficient  number  of  oravats  ar- 
ranged after  the  plan  indicated. 

2.  For  fractures  of  the  radius. 

This  bone  may  be  broken  at  its  neck,  at  its  carpal  extremity, 
or  at  any  intermediate  point.  The  first  and  the  last  cases 
should  be  treated  as  if  both  bones  of  the  fore-arm  were  broken  ; 
the  hand  may  be  placed  in  a  state  of  semi-pronation,  or  in  su- 
pination,  as  advised  by  Lonsdale. 

It  sometimes  happens  that  the  lower  fragment  of  the  radius, 
when  the  fracture  is  near  the  carpal  extremity,  is  driven  very 
forcibly  towards  the  ulna,  so  as  to  require  the  operation  of  a 
force  gradually  exerted,  and  for  a  considerable  time,  to  restore 
it  to  its  natural  line.  For  such  cases  Dupuytren  recom- 
mended the  following  plan  of  treatment :  "  Take  a  bar  of 
iron  about  an  inch  wide  and  of  the  length  of  the  fore-arm, 
and  which  at  its  lower  extremity,  opposite  the  part  corre- 
sponding with  the  wrist,  curves  downwards  in  a  semicircle, 
to  the  concavity  of  which  some  buttons  are  placed  at  equal 
distances."  Along  the  ulnar  edge  of  the  fore-arm,  place  a 
firm  compress,  extending  from  just  above  the  extremity  of 
the  bone  upwards,  about  an  inch  thick  at  the  lower  end,  and 
gradually  tapering :  upon  this  compress  apply  the  splint,  its 
straight  portion  extending  from  the  elbow  to  the  termination 
of  the  compress,  and  secure  it  in  this  position  by  a  roller 
which,  on  reaching  the  hand,  causes  the  latter  to  approximate 
the  curve  of  the  bar, 

more  or  less,  according  FlG- 54- 

to  the  amount  of  force 
required  to  rectify  the 
displacement  of  the 
lower  fragment  of  the 
radius,  with  which  the 
hand  is  connected. 
(See  fig.  54.) 

The  most  common  seat  of  fracture  of  the  radius  is  at  the 
lower  or  carpal  extremity  of  the  bone.  Two  varieties  of  this 
accident  have  been  described :  one  by  Dr.  Colles,  of  Dublin, 
in  the  Edinburgh  Medical  and  Surgical  Journal,  1814,  and 
the  other  by  Dr.  J.  R.  Barton,  in  the  Philadelphia  Medical 
Examiner,  1838. 

Cones'1  fracture  usually  occurs  from  three-fourths  to  one 


152  FRACTURES    OF    THE 

inch  above  the  radio-carpal  articulation,  and  is  very  much 
more  commonly  transverse  than  ohlique.  (R.  W.  Smith, 
Treatise  on  Fractures,  &c.,  Dublin,  1847.)  Barton  s  frac- 
ture, on  the  other  hand,  extends  obliquely  into  the  wrist-joint ; 
and,  perhaps  in  consequence  of  this  implication  of  the  joint 
directly,  there  is  likely  to  be  more  inflammation  of  the  articu- 
lation, and  more  permanent  impairment  of  its  motion  than  in 
case  of  Colles'  fracture. 

The  resulting  deformity  is  very  much  the  same  in  both 
forms  of  the  injury. 

In  this  accident,  the  lower  fragment  of  the  radius,  and 
with  it  the  carpus,  is  drawn  upwards  upon  the  back  of  the 
fore-arm,  as  is  represented  in  the  annexed  drawing  (fig.  55.) 

FIG.  55. 


The  treatment  as  advised  by  Dr.  Barton,  is  very  simple: 
place  the  fragments  in  apposition  by  drawing  down  the  hand, 
the  upper  part  of  the  fore-arm  being  fixed ;  then  place  a 
compress  upon  the  posterior  face  of  the  lower  fragment,  and 
another  on  the  anterior  face  of  the  upper,  and  apply  padded 
splints  along  the  anterior  and  posterior  faces  of  the  fore-arm, 
as  directed  for  the  other  fractures ;  the  splints  should  extend 
from  the  elbow  to  the  ends  of  the  fingers.  After  the  lapse 
of  a  week  or  ten  days,  passive  motion  of  the  wrist  and  finger- 
joints  should  be  commenced  and  repeated  daily  for  five  or 
six  weeks,  when  the  splints  may  be  omitted.  When  the 
dressings  are  removed  from  time  to  time,  the  hand,  and  indeed 
the  whole  fore-arm  also,  should  be  bathed,  otherwise  the  con-1 
finement  will  be  attended  with  want  of  cleanliness  of  the 
part,  and  with  a  very  unpleasant  sour  smell,  disagreeable 
both  to  the  patient  and  to  the  surgeon. 

The  line  of  fracture  sometimes  assumes  the  opposite  direc- 


BONES     OF    THE    FOEE-ABM. 


153 


tion,  extending  from  the  dorsal  face  of  the  radius  obliquely 
upwards  to  its  palmar  surface.  The  treatment  is  the  same  as 
in  the  first  variety  of  the  injury,  a  slight  change  being  made 
in  the  disposition  of  the  compresses  to  correspond  with  the 
different  kind  of  deformity,  as  will  at  once  suggest  itself  to 
the  dresser. 

During  the  continuance  of  the  splints,  and  for  some  time 
later,  the  fore-arm  should  be  supported  in  a  sling. 

The  frequency  with  which  these  fractures  of  the  radius 
occur,  and  the  considerable  impairment  of  the  mobility  of 
the  wrist  and  the  finger-joints  which  result  from  them,  and 
which  is  sometimes  permanent,  especially  in  elderly  persons, 
and  in  those  who  are  subject  to  chronic  rheumatism,  have 
induced  surgeons  to  devote  a  great  degree  of  attention  to 
their  treatment.  Consequently,  the  simple  plan  of  treatment 
above  described,  has  been  variously  modified. 

M.  Nelaton  recommends  the  following  method:  Bring 
the  fragments  into  proper  apposition  by  the  necessary  exten- 
sion, counter-extension,  and  other  manipulations;  place  the 
fore-arm  in  a  position  midway  between  pronation  and  supina- 
tion,  the  hand  being  well  brought  down  to  its  ulnar  side ; 
then  apply  a  well  padded  pistol-shaped  wooden  splint,  extend- 
ing from  the  elbow  to  the  extremity  of  the  fingers,  along  the 
outer  side  of  the  fore-arm,  with  a  compress  opposite  the  lower 
fragment,  and  a  straight  splint  along  the  inner  face,  reaching 
from  the  elbow  to  the  wrist,  well  padded  opposite  the  upper 
fragment,  and  along  the  radial  border  of  the  fore-arm,  to  coun- 
teract the  tendency  of  this  part  of  the  bone  to  pronation. 
(See  fig.  56.) 

FIG.  56. 


154 


FRACTURES    OF    THE 


Dr.  Bond,  of  this  city,  has  contrived  recently  a  splint,  by 
the  use  of  which  the  liability  to  stiffness  of  the  joints  is  very 
much  diminished.  The  splint  is  made  of  light  wood,  cut  to 
the  shape  of  the  fore-arm,  and  extends  from  the  elbow  to  the 
second  joint  of  the  fingers.  (Fig.  57.)  To  its  palmar  ex- 


FIG.  57. 


tremity  is  to  be  firmly  attached,  by  screws  or  nails,  a  carved 
and  rounded  block  of  wood  of  the  size  of  the  patient's  hand, 
which  the  latter  may  grasp  when  the  arm  is  extended  upon 
the  splint.  The  splint  may  or  may  not  be,  according  to  fancy 
or  convenience,  covered  with  binders'  board,  the  edges  of 
which  shall  project  beyond  the  sides  of  the  splint,  and  be 
turned  up,  so  as  to  form  a  kind  of  box  for  the  arm.  (Fig.  58.) 

FIG.  58. 


If  the  binders'  board  be  not  used,  the  splint  is  wrapped,  as 
usual,  in  a  roller  or  in  muslin,  the  arm  is  placed  upon  it,  the 
fingers  are  allowed  to  rest  comfortably,  or  to  be  moved  at 
pleasure,  upon  the  carved  block ;  a  compress  is  to  be  placed 
under  the  arm  at  the  point  of  fracture,  just  large  enough  to 
fill  up  any  vacuity  which  the  shape  of  the  member  may  occa- 
sion after  the  fracture  has  been  reduced.  Another  compress 
is  to  be  laid  upon  the  dorsal  face  of  the  limb,  opposite  the 
first,  and  the  arm  lightly  secured  to  the  splint  by  a  roller. 
The  patient  is  permitted  to  use  as  much  motion  of  his  fingers 


BONES    OF    THE    FORE-ARM.  155 

and  wrist  as  the  apparatus  will  allow.     (See  Dr.  Bond's  paper 
in  the  American  Journal  of  Medical  Sciences,  April,  1852.) 

If  Dr.  Bond's  splint  be  not  at  hand,  (any  surgeon,  how- 
ever, can  make  one  in  a  few  minutes,  of  a  shingle  and  a  block 
of  pine  wood),  a  common  splint  of  the  proper  length  can  be 
prepared  in  imitation  of  Dr.  Bond's,  by  wrapping  a  roller 
about  it,  as  recommended  by  Dr.  Hays,  and  as  illustrated 
in  the  annexed  drawing.  (Fig.  59.) 

FIG.  59. 


Frequently,  patients  become  wearied  of  any  splint,  after  a 
certain  time,  the  confinement  of  the  arm  in  a  particular  posi- 
tion being  irksome  to  them.  If  this  be  the  case  in  the  treat- 
ment of  these  fractures  by  Bond's,  Hays',  Nelaton's  or  Bar- 
ton's plan,  the  splint  suggested  by  Good,  which  is  applied  to 
the  back  of  the  fore-arm,  may  be  employed. 

Latterly,  it  has  been  proposed  by  Professor  Fauger,  of 
Copenhagen,  to  treat  these  fractures  without  splints.  "  The 
hand  having  been  brought  into  a  position  of  strong  flexion, 
the  fore-arm  is  placed,  pronated,  on  an  oblique  plane,  with 
the  carpus  highest,  the  hand  being  permitted  to  hang  freely 
down  the  perpendicular  end  of  the  plane."  (London  Lancet, 
May  8,  1847.) 

3.  For  fractures  of  the  ulna. 

The  ulna  may  be  broken  in  its  shaft,  or  at  the  coronoid  or 
olecranon  processes.  The  first-named  variety  is  treated  after 
the  same  method  as  when  both  bones  are  involved ;  fractures 
of  the  processes  require  a  different  plan. 

When  the  coronoid  process  is  broken  off  from  its  bony  and 
ligamentous  connexions,  the  brachialis  anticus  muscle,  which 
is  inserted  upon  it,  draws  it  up  on  the  lower  portion  of  the 
humerus;  and  the  chief  difficulty  in  treating  this  accident 


156  FRACTURES    OF    THE 

successfully  consists  in  counteracting  entirely  the  force  of 
this  muscle,  so  as  to  maintain  the  fragments  in  perfect  appo- 
sition. There  is  also  another  cause  of  failure,  since  when 
this  process  is  detached,  "  like  the  head  of  the  thigh-bone,  it 
loses  its  ossific  nourishment,  and  has  no  other  than  a  liga- 
mentous  support.  Its  life  is  preserved  by  the  vessels  of  the 
reflected  portion  of  the  capsular  ligament  upon  the  end  of 
the  bone,  which  do  not  appear  capable  of  supporting  the 
least  attempt  at  ossific  union."  (Sir  A.  Cooper,  op.  cit., 
p.  406.) 

For  the  treatment  of  this  injury,  apply  a  roller  from  the 
ends  of  the  fingers,  around  the  fore-arm  and  about  the  elbow, 
making  firm  pressure  upon  the  restored  process,  through  the 
intervention  of  a  compress,  and  then  continue  the  roller 
around  the  arm,  so  as  to  confine  the  brachialis  anticus :  over 
the  roller  place  an  angular  splint,  extending  from  near  the 
the  head  of  the  humerus  to  the  fingers,  along  the  anterior 
surface  of  the  limb,  and  retain  it  thus  by  a  roller.  The  fore- 
arm should  be  supported  in  a  sling,  and  the  apparatus  should 
be  worn  for  six  or  eight  weeks,  passive  motion  being  resorted 
to  very  cautiously.  The  splint  which  is  employed  should  be 
flexed  at  rather  less  than  a  right  angle,  in  order  that  the  bra- 
chialis anticus  may  be  relaxed  as  much  as  possible,  and  every 
facility  be  afforded  for  a  bony  union  of  the  fragments. 

The  angular  splints  for  the  upper  extremity  may  be  made 
with  the  angle  fixed,  or  this  may  be  movable  and  changeable 
at  pleasure,  the  two  segments  of  the  splint  being  fastened  at 
the  desired  angle,  by  a  pin  traversing  both  portions :  if  the 
former  arrangement  be  adopted,  it  will  be  necessary  to  have 
a  multiplicity  of  splints  made  at  different  angles ;  by  the 
latter,  the  same  splint  will  answer  the  purposes  of  all  the 
others. 

The  olecranon  process  is  more  frequently  broken  than  the 
coronoid,  and  the  reparation  of  the  injury  is  equally,  if  not 
more,  difficult.  The  triceps  muscle  acts  upon  the  fragment 
of  bone  to  great  advantage,  so  that  when  the  ligamentous 
fibres  are  severed,  which  connect  it  with  surrounding  points, 
the  retraction  is  sometimes  very  great. 

The  indication  is,  of  course,  to  relax  the  muscle,  so  that 
the  fragments  may  be  kept  in  apposition ;  the  fore-arm  should 


BONES    OF    THE    FORE-ABM.  157 

be  extended  upon  the  arm,  and  some  means  should  be  resorted 
to  for  securing  the  broken  surfaces  together. 

Sir  Astley  Cooper  advises  the  following  plan  of  treatment : 
—  "  If  there  be  much  swelling  and  contusion,  it  is  right  to 
apply  evaporating  lotions  and  leeches  for  two  or  three  days ; 
and  after  the  inflammation  is  reduced,  a  bandage  should  be 
applied." — "If  the  swelling  and  inflammation  do  not  prevent 
it,  the  surgeon  is,  at  once,  to  place  the  arm  in  a  straight  posi- 
tion, and  to  press  down  the  upper  portion  of  the  fractured 
olecranon,  until  he  brings  it  in  contact  with  the  ulna ;  a  piece 
of  linen  is  then  laid  longitudinally  on  each  side  of  the  joint ; 
a  wetted  roller  is  applied  above  the  elbow,  and  another  below 
it;  the  extremities  of  the  linen  are  then  to  be  doubled  down 
over  the  rollers  and  tightly  tied,  so  as  to  cause  an  approxi- 
mation;  thus  the  portions  of  bone  are  brought  and  held 
together ;  a  splint  well  padded  is  to  be  applied  upon  the  fore 
part  of  the  arm,  to  preserve  it  in  a  straight  position,  and  con- 
fined to  it  by  a  circular  bandage ;  the  whole  finally,  is  to  be 
frequently  wetted  with  spirits  of  wine  and  water."  (See 
fig.  60.) 

FIG.  60. 


"  In  a  month  the  splint  is  to  be  removed,  and  passive  mo- 
tion is  to  be  begun :  but,  if  .it  be  attempted  earlier,  the  ole- 
cranon will  be  separated  from  the  shaft  of  the  bone,  and  the 
ligament  will  become  lengthened  and  weakened;  all  attempts 
at  motion  must,  therefore,  be  made  with  the  greatest  gentle- 
ness." (Sir  A.  Cooper,  op.  cit.,  p.  410.) 

Another  method  of  treating  this  fracture  consists  in  apply- 
ing a  roller  from  the  fingers  to  the  elbow,  then  drawing  down 
the  fragment  of  the  olecranon  to  its  natural  situation  ;  and 
while  an  assistant  holds  it  thus,  by  means  of  a  compress 
placed  just  above  it,  the  surgeon  makes  a  few  figure-8  turns 
around  the  elbow,  permanently  confining  the  compress  and 


158  FRACTURES    OF    THE 

the  process  of  bone,  and  exhausts  the  roller  upon  the  upper 
arm.  A  straight  splint  is  now  taken  and  laid  upon  the  front 
of  the  limb,  extending  from  near  the  head  of  the  humerus 
to  the  wrist ;  some  cotton  should  be  interposed  between  the 
splint  and  the  bandage  at  the  bend  of  the  elbow,  in  order 
to  fill  up  the  vacuity  at  this  point, — the  fore-arm  not  being 
extended  quite  to  the  utmost, —  and  the  whole  secured  by  an- 
other roller. 

The  same  precautions,  with  regard  to  the  institution  of 
passive  motion,  are  to  be  attended  to,  as  in  the  other 
method. 

The  extension  of  the  fore-arm,  and  the  confinement  of  the 
fragment  of  the  olecranon,  may  be  effected  also  by  the  "  ole- 
crano-metacarpal  cravat"  of  Mayor,  as  follows:  —  Extend 
the  fore-arm,  and  place  upon  its  anterior  face  a  pasteboard 
splint  moulded  to  its  form,  and  reaching  from  the  lower  third 
of  the  upper  arm  to  the  fingers ;  draw  down  the  fractured 

Erocess  to  the  corresponding  surface  of  the  ulna,  and  upon  it 
ty  a  compress,  which  should  be  held  by  an  assistant ;  then 
pass  a  cravat  around  the  lower  extremity  of  the  humerus,  so 
as  to  retain  in  place  the  splint  and  the  compress,  and  knot  it 
behind,  leaving  the  tails  hanging  about  half  way  down  the 
back  of  the  fore-arm ;  to  the  palm  of  the  hand,  below  the  ball 
of  the  thumb,  apply  the  centre  of  another  cravat,  and  tie  it 
upon  the  back  of  the  wrist,  thus  securing  the  lower  extremity 
of  the  splint,  the  tails  of  the  cravat  being  free ;  now  tie  the 
ends  of  the  two  cravats  together.  (See  fig.  61.) 

FIG.  61. 


This  method  can  scarcely  be  relied  upon  for  the  permanent 
treatment  of  this  form  of  fracture,  when  the  other  methods 
can  be  employed. 

Desault  advises  that  the  fore-arm  should  be  maintained  in  a 


WRIST    AND    HAND.  159 

state  between  semi-flexion  and  extension,  in  case  of  fracture 
of  the  olecranon  process,  and  that  a  splint  slightly  curved  be 
applied  on  the  anterior  face  of  the  limb,  as  in  the  plans 
already  mentioned. 

In  compound  fracture  of  this  portion  of  the  bone,  the  limb 
should  be  extended  by  means  of  a  splint  laid  upon  its  anterior 
face,  and  confined  thus  by  a  roller,  which,  however,  should  not 
cover  the  wound ;  the  edges  of  the  latter  should  be  retained  in 
apposition  by  strips  of  adhesive  plaster,  and  over  it  a  piece 
of  lint  saturated  with  blood  or  solution  of  starch  should  be  ap- 
plied, the  whole  being  enveloped,  and  the  elbow  tightly  con- 
fined to  the  splint,  by  a  bandage  of  Scultetus.  The  patient 
should  be  kept  in  bed  with  the  arm  extended  on  pillows,  the 
hand  elevated  rather  higher  than  the  shoulder.  If  no  unplea- 
sant symptom  occur,  the  dressing  should  be  undisturbed  for  a 
week  or  ten  days.  Treated  in  this  way,  these  injuries  are 
sometimes  very  well  recovered  from.  But  if  inflammation  and 
suppuration  come  on,  the  accident  must  be  treated  as  ordinary 
compound  fractures  presenting  the  same  symptoms ;  here 
again,  adhesive  strips  properly  applied,  so  as  to  maintain  the 
necessary  degree  of  extension  and  counter-extension,  will  be 
found  of  great  service  in  the  treatment. 

Partial  fractures  of  the  bones  of  the  fore-arm,  those  namely 
in  which  some  of  the  fibres  only  of  the  bone  are  ruptured,  the 
others  being  bent,  require  the  same  treatment,  in  general 
terms,  as  the  complete  fractures.  After  the  line  of  the  bone 
has  been  restored,  however,  by  suitable  manipulations,  there 
is  usually  less  disposition  to  a  reproduction  of  the  deformity, 
and  hence  less  compressing  force  is  required  to  counteract  it ; 
generally,  too,  union  takes  place  sooner  than  in  the  other 
cases,  and  the  splints  need,  not  be  worn  so  long  as  in  the 
latter. 


SECTION  III. 
FOR   FRACTURES    OF    THE    BONES    OF   THE   WRIST    AND   HAND. 

1.  Fractures  of  the  carpal  bones  are  almost  necessarily  com- 
pound and  attended  with  much  injury  to  the  soft  parts;  they 


160  FRACTURES  OF  THE  WRIST  AND  HAND. 

require  no  especial  apparatus  to  keep  them  in  place.  The 
best  plan  of  treatment  in  such  cases  is,  to  adapt  a  splint  to 
the  lower  part  of  the  fore-arm  and  hand,  increasing  in  width 
at  the  wrist,  being  retained  lightly  in  this  situation  by  a  roller, 
or  bandage  of  Scultetus ;  if  the  wound  is  on  the  palmar  sur- 
face of  the  wrist,  the  splint  should  be  applied  to  the  back  of 
the  fore-arm  and  hand,  and  vice  versli.  If,  as  is  generally  the 
case,  there  is  no  probability  of  securing  direct  closure  of  the 
wound,  poultices,  or  water-dressings,  should  be  laid  upon  it, 
at  first,  or  the  treatment  by  irrigation  should  be  adopted,  and 
other  applications  used  as  required:  the  fore-arm  and  hand 
should  be  supported  in  a  sling,  or  should  repose  upon  a  pillow, 
as  most  expedient. 

2.  Simple  fractures  of  the  metacarpal  bones  are,  in  gene- 
ral, attended  with  but  little  displacement ;  after  the  fragments 
have  been  restored  to  apposition,  they  are  easily  retained  in 
situ  by  merely  laying  a  compress  upon  the  bone,  and  confining 
it  thus,  with  the  hand  and  fore-arm  upon  a  broad  splint  as 
above. 

3.  Simple  fractures  of  the  bones  of  the  fingers  require  for 
their  treatment  merely  that  the  fingers  shall  be  supported  by 
a  thin  strip  of  pasteboard  placed  on  each  side  of  them,  and 
confined  by  a  piece  of  tape  applied  in  circular  turns.     For 
greater  security  and  to  insure  perfect  repose  to  the  injured 
finger,  the  hand  and  fore-arm  should  be  bound  to  a  splint,  as 
in  the  cases  just  considered,  and  supported  in  a  sling. 

4.  Compound  fractures  of  the  metacarpal  and  phalangeal 
bones  are  often  met  with,  as  occasioned  by  the  bursting  of 
firearms,  the  explosion  of  rocks,  and  by  the  hand  becoming 
entangled  in  machinery.     Such  injuries  appear  very  formi- 
dable at  first,  and  as  if  beyond  reparation  ;  but  the  hand  is  of 
such  vast  importance  to  the  patient, — and  the  accident  gene- 
rally happens  to  those  who  earn  their  subsistence  by  their 
daily  labour, — that  an  attempt  at  saving  it  should  be  made, 
and  the  most  unpromising  cases  do  very  often  recover  with 
very  useful  hands. 

A  splint  long  enough  to  extend  from  the  elbow  to  the  ends 
of  the  fingers,  or  a  little  beyond  them,  and  grooved  on  its 
palmar  portion  to  receive  the  fingers  (see  fig.  62),  should  be 
padded  with  cotton,  or  covered  with  a  poultice  or  other 
suitable  dressing,  and  placed  underneath  the  limb :  a  roller 


FBACTURES    OF    THE    WRIST    AND    HAND.  161 

should  be  passed  around  the  fore-arm  and  splint,  to  retain  the 
latter  in  place,  and  this,  with  the  weight  of  the  dressings  that 
are  laid  upon  the  hand,  will  be  found  in  most  cases  to  be  suf- 


FIG.  62. 


ficiently  retentive  for  the  latter.  Generally,  the  continued 
application  of  cold  water  upon  the  lacerated  parts,  will  prove 
the  best  and  the  most  agreeable  dressing  that  can  be  em- 
ployed ;  it  should  be  used  as  advised  under  the  head  of  irri- 
gation, in  the  first  part  of  this  volume.  The  feelings  of  the 
patient  form  the  best  guide  as  to  the  length  of  time  during 
which  this  application  should  be  retained ;  so  long  as  he  finds 
it  comfortable,  it  may  be  continued ;  so  soon  as  he  complains 
of  increasing  pain  in  the  injured  part,  or  if  he  becomes  chilly 
under  its  use,  it  will  be  best  to  substitute  for  it  a  warm  poul- 
tice, or  folds  of  soft  lint  saturated  with  warm  water ;  and  the 
dressings  should  be  varied  to  suit  the  particular  conditions  of 
the  wound.  When  there  is  free  suppuration,  particularly  in 
warm  weather,  the  bran  dressing  will  be  found  very  service- 
able, as  it  not  only  absorbs  the  discharges,  but  covers  the 
injured  parts  and  renders  it  less  likely  to  be  infested  with 
vermin,  —  a  source  of  much  trouble  and  annoyance  both  to 
the  surgeon  and  the  patient.  (Some  of  the  strong  aromatic 
oils  are  of  service  in  destroying  these  nuisances;  but  it  is 
generally  necessary  to  dislodge  them  from  their  burrowing- 
places  by  means  of  the  dissecting  forceps,  and  by  injecting  a 
stream  of  water  upon  them  from  a  small  syringe.) 

After  the  suppuration  has  in  a  measure  ceased,  and  the 
wounds  have  assumed  the  appearance  of  healthy  ulcers,  the 
hand  may  be  placed  upon  a  flat  splint,  of  the  same  shape  as 
the  other,  and  the  bones  pressed  into  proper  line,  by  inserting 
pledgets  of  lint  between  the  fingers  and  using  gentle  com- 
pression upon  the  whole  hand  by  the  folds  of  a  bandage  of 
Scuketus,  enveloping  both  the  hand  and  the  splint ;  the  ten- 
dency to  recurring  displacement  of  the  fragments  of  bone  is 
14* 


162          FRACTURES    OF    THE   WRIST    AND    HAND. 

so  slight  in  these  cases,  that  very  little  force  is  requisite  to 
keep  them  in  tolerable  apposition. 

During  the  early  part  of  the  treatment,  the  patient  should 
be  kept  in  bed,  with  the  arm  reposing  upon  pillows,  the  hand 
somewhat  elevated;  in  the  latter  stages,  he  may  be  allowed 
to  leave  the  bed,  with  the  arm  supported  in  a  sling. 

The  disposition  of  the  pus  to  run  underneath  the  soft  parts, 
forming  collections  at  points  remote  from  the  wound,  should 
be  counteracted  by  position,  by  compression,  and  finally,  if  it 
can  be  prevented  in  no  other  way,  by  incisions  practised 
wherever  a  deposit  is  formed. 


CHAPTER  V. 

ON  THE  APPARATUS  AND   DRESSINGS   FOR  FRACTURES   OF 
THE   BONES   OF   THE   LOWER    EXTREMITY. 


SECTION  I. 
FOR    FRACTURES    OF    THE    OS    FEMORIS. 

GREATER  difficulty  is  experienced  in  the  treatment  of  frac- 
tures of  the  femur,  than  in  those  of  any  other  bone.  The 
constant  action  of  powerful  muscles ;  the  injurious  effects  of 
pressure  upon  the  soft  parts,  from  long-continued  position, 
and  from  the  compression  of  bandages ;  the  hurtful  influence 
upon  the  general  health  of  protracted  confinement,  and  the 
direct  impression  upon  the  system  resulting  from  the  injury 
itself,  are  all  to  be  combated  in  the  same  case.  The  attention 
which  has  been  devoted  to  the  consideration  of  this  subject, 
has  been  proportioned  to  its  importance. 

The  proper  position  in  which  the  thigh  shall  be  maintained 
during  the  treatment,  is  the  main  point  of  discussion  among 
surgeons  —  some  preferring  the  flexed,  others  the  extended 
position  of  the  limb.  A  variety  of  apparatus,  more  or  less 
complicated  in  structure  and  arrangement,  has  been  contrived 
with  reference  to  each  plan  of  treatment. 

1.  Modes  of  treatment,  the  thigh  being  in  the  flexed  posi- 
tion.— This  position  is  most  in  vogue  in  Great  Britain  ;  it  was 
first  particularly  recommended  by  Mr.  Pott,  who  founded  it 
upon  the  idea  that  it  is  possible  "  to  put  the  limb  into  such  a 
position  as  shall  relax  the  whole  set  of  muscles  belonging  to, 
or  in  connexion  with,  the  broken  bone."  This  idea  is  mani- 
festly incorrect,  since  the  position  which  relaxes  the  flexor" 
muscles  renders  the  extensors  more  tense  ;  that  which  approxi- 
mates the  extremities  of  the  adductors  has  the  reverse  effect 
upon  the  abductors. 

The  following  is  the  plan  of  treatment  adopted  by  Mr. 

(163)  ' 


164  FRACTURES    OF    THE    OS    FEMORIS. 

Pott :  —  "  The  position  of  the  fractured  os  femoris  should  be 
on  its  outside,  resting  on  the  great  trochanter ;  the  patient's 
whole  body  should  be  inclined  to  the  same  side ;  the  knee 
should  be  in  a  middle  state  between  perfect  flexion  and  exten- 
sion, or  half-bent ;  the  leg  and  foot,  lying  on  their  outside 
also,  should  be  well  supported  by  smooth  pillows,  and  should 
be  rather  higher  in  their  level  than  the  thigh ;  one  very  broad 
splint  of  deal,  hollowed  out  and  well  covered  with  wool,  rag, 
or  tow,  should  be  placed  under  the  thigh,  from  above  the 
trochanter  quite  below  the  knee ;  and  another,  somewhat 
shorter,  should  extend  from  the  groin  to  below  the  knee  on 
the  inside,  or  rather,  in  this  posture,  on  the  upper  side.  The 
bandage  should  be  of  the  eighteen-tail  kind,  and  when  the 
bone  has  been  well  set,  and  the  thigh  well  placed  upon  the 
pillow,  it  should  not,  without  necessity,  (which  necessity  will, 
in  this  method,  seldom  occur,)  be  moved  from  it  again  until 
the  fracture  is  united ;  and  this  union  will  always  be  accom- 
plished in  more  or  less  time,  in  proportion  as  the  limb  shall 
have  been  more  or  less  disturbed."  (Cooper's  Surg.  Diet.) 
The  chief  and  sufficient  objections  to  this  plan  of  treatment 
are,  that  the  means  employed  are  insufficient  to  keep  the 
ends  of  the  fragments  in  apposition,  and  too  insecure  against 
sudden  and  accidental  movements  of  the  limb,  or  of  the 
whole  body ;  and  that  the  pressure  exerted  upon  the  tro- 
chanter for  the  space  of  many  weeks  is  too  great  to  be  safely 
borne. 

There  are  some  cases,  however,  in  which  this  position  may 
be  adopted  as  a  temporary  one ;  these  will  be  mentioned  here- 
after. 

Sir  C.  Bell  recommended  another  method  of  treating  this 
class  of  injuries  in  the  flexed  position  of  the  thigh : — The  pa- 
tient lies  upon  his  back,  while  the  limb  is  supported  upon  a 
double  inclined  plane,  one  portion  of  which  extends  from  the 
tuberosity  of  the  ischium  to  the  ham,  and  the  other  from  the 
ham  to  the  heel ;  straight  splints  are  confined  to  the  outer  and 
inner  sides  of  the  thigh.  Numerous  apparatus  have  been 
contrived,  in  modification  of  the  original  suggestion  of  Bell, 
some  of  which  are  much  used  in  England. 

2.  The  plan  of  treatment  by  the  straight  position  of  the 
limb  was  first  employed  by  Desault.  In  this  method,  a  con- 
stant extending  and  counter-extending  force  is  maintained 


FRACTURES    OF    THE    OS    FEMORIS.  165 

upon  the  fragments,  while  lateral  pressure  is  exerted  upon  the 
limb  by  means  of  splints  and  bandages.  The  original  appa- 
ratus of  Desault  has  been  modified  and  improved  upon,  in  va- 
rious ways,  by  European  and  American  surgeons,  so  that  frac- 
tures of  the  thigh  may  be  more  successfully  treated  in  the 
straight  position,  than  in  any  other. 

The  os  femoris  may  be  broken  at  its  condyloid,  or  trochan- 
teric  extremity,  or  at  any  point  in  its  shaft ;  and  although  the 
general  plan  of  treating  the  injury,  at  whatever  part  the  frac- 
ture may  have  occurred,  is  the  same,  yet  there  are  some  minor 
points  of  difference,  which  are  nevertheless  of  importance  in 
practice. 

1.  For  fractures  occurring  in  the  shaft  of  the  bone. 

The  injury  may  be  simple  or  compound,  and  the  line  of  frac- 
ture transverse  or  oblique.  Displacement  of  the  fragments 
almost  invariably  occurs,  even  when  the  bone  is  transversely 
broken,  for  the  force  which  caused  the  fracture  nearly  always 
deranges  the  axis  of  the  bone,  pushing  the  two  portions  from 
contact  with  each  other,  and  then  the  muscles  have  uncon- 
trolled action,  and  draw  the  lower  fragment  upwards,  above, 
or  underneath,  the  superior.  Even  if  the  contact  of  the  ex- 
tremities of  the  two  portions,  at  the  point  of  fracture,  be  not 
completely  sundered  by  the  original  violence,  the  muscles 
which  pass  from  the  pelvis  to  the  lower  extremity  of  the  fe- 
mur will  act  upon  the  latter,  and  thus  derange  the  natural 
line  of  the  bone.  But  when  the  fracture  is  oblique,  shorten- 
ing of  the  limb  is  a  necessary  consequence,  and  its  degree  will 
depend  very  much  upon  the  muscular  development  of  the 
patient. 

The  solution  of  continuity  may  occur  at  any  point  between 
the  smaller  trochanter  and  the  condyles,  but  its  most  frequent 
seat  is  within  the  lower  two-thirds  of  the  bone.  The  inferior 
fragment  is  drawn  upwards  and,  generally,  inwards  by  the 
extensor  and  adductor  muscles,  while  the  superior  is  elevated 
at  its  lower  extremity  by  the  action  of  the  iliacus  internus  and 
psoas  magnus,  and  this  tilting-up  of  the  fragment  will  be 
greater  or  less,  as  the  fracture  is  near  to,  or  remote  from,  the 
insertion  of  these  muscles.  The  direction  which  the  upper 
portion  of  the  bone  will  assume  will  be  modified  also  by  the 
operation  upon  it  of  the  glutaeus  maximus,  if  the  fracture  be 
above  the  middle  of  the  shaft, — it  will  be  thrown  outwards. 


166  FRACTURES    OF    THE    OS    FEMORIS.' 

And  farther  there  is  almost  invariably  a  considerable  degree 
of  eversion  of  the  foot  as  well  as  of  the  lower  end  of  the  upper 
fragment,  in  consequence  of  the  weight  of  the  limb,  or  the 
contraction  of  the  external  rotator  muscles  of  the  thigh.  The 
choice  and  management  of  the  apparatus  employed  to  treat  a 
case  of  fracture  of  the  shaft  of  the  femur  must,  of  course,  be 
based  upon  its  adaptation  to  the  counteraction  of  these  causes 
of  deformity.  It  will  be  most  convenient,  with  reference  to 
this  point,  to  consider,  first,  the  different  kinds  of  apparatus 
used  in  the  treatment  of  these  injuries,  in  the  flexed  position 
of  the  limb ;  and,  secondly,  those  adapted  to  the  extended 
position. 

The  plan  proposed  by  Pott  has  been  already  described,  and 
the  objections  to  it  have  been  stated :  it  should  not  be  adopted 
in  ordinary  cases  as  a  permanent  method  of  treatment,  but 
in  some  instances  it  may  be  used  with  advantage.  Thus, 
when  there  is  much  contusion  of  the  soft  parts,  or  in  cases 
of  compound  fracture  with  the  wound  on  the  under  surface 
of  the  thigh,  as  may  perhaps  happen  occasionally,  it  is  the 
only  plan  which  can  be  resorted  to,  —  temporarily  in  the  first 
class  of  cases,  and  as  a  permanent  mode  in  the  latter. 

The  apparatus  contrived  by  Sir  Charles  Bell  consisted  of 
two  boards,  ten  or  eleven  inches  wide,  one  of  which  was  made 
to  extend  from  the  tuberosity  of  the  ischium  to  the  popliteal 
flexure,  and  the  other  from  the  latter  point  to  the  heel :  these 
two  portions  of  the  apparatus  were  united  at  an  angle  under 
the  knee-joint,  while  their  other  extremities  were  connected 
by  a  horizontal  piece,  which  served  also  to  support  the 
double  inclined  plane  upon  the  bed.  Holes  were  pierced 
along  the  margin  of  the  inclined  planes,  in  which  pegs  were 
inserted  to  steady  the  limb.  When  about  to  be  used,  the 
apparatus  was  placed  upon  a  mattrass,  the  inclined  surfaces 
covered  with  a  cushion,  and  the  limb  laid  upon  it,  so  that  the 
under  surface  of  the  knee  should  correspond  with  the  angle 
of  the  plane,  and  the  tuberosity  of  the  ischium  should  check 
against  the  upper  extremity  of  the  horizontal  board.  A  lath 
splint  was  bound  to  the  upper  surface  of  the  thigh,  and 
another  along  the  inner  face  of  the  same. 

Many  modifications  of  this  simple  apparatus  have  been 
contrived  since  the  original  was  proposed.  Mr.  Lonsdale's 
book  contains  a  description  of  the  one  which  was  —  at  the 


FRACTURES    OF    THE    OS    FEMORIS.  167 

time  he  wrote,  1838,  —  in  ordinary  use  at  the  Middlesex 
Hospital,  London,  and  which,  he  thinks,  "possesses  all  the 
advantages  that  the  more  complicated  ones  are  said  to  have." 
It  differs  from  the  one  just  described  in  having  the  planes 
joined  by  means  of  a  hinge  at  the  point  corresponding  with 
the  knee ;  and  the  same  sort  of  union  exists  between  the 
thigh-piece  and  the  horizontal  frame,  while  the  portion  on 
which  the  leg  reposes  may  be  fixed  at  any  angle  upon  the 
latter,  by  means  of  a  serrated  edge.  "  The  letter  A  marks 
the  screw  that  secures  a  slide  in  the  thigh-portion  of  the 
plane,  to  allow  of  the  latter  being  adapted  to  limbs  of  dif- 
ferent lengths."  (See  fig.  63.)  A  slide,  having  a  foot-board 

FIG.  63. 


attached  to  it,  could  be  very  easily  adapted  to  the  lower  plane, 
so  that  it  might  be  fastened  at  a  suitable  distance  from  the 
angle,  to  correspond  with  the  length  of  the  leg. 

In  making  use  of  this  apparatus,  the  length  of  the  thigh 
and  leg  portions  of  the  plane  should  be  made  to  agree  with 
that  of  the  unbroken  thigh  and  leg ;  "  the  points  from  which 
the  measurement  should  be  taken  are  the  tuberosity  of  the 
ischium  and  the  angle  of  the  knee,"  and  the  latter  point  and 
the  heel;  "and  the  plane -should  be  applied  to  the  sound 
limb  first,  to  see  that  it  corresponds  exactly  with  the  points 
above  mentioned."  (Lonsdale,  p.  298.)  It  is  advised  to 
have  the  cushion  made  of  flannel  folded  several  times,  as  this 
is  supposed  to  offer  a  more  smooth  and  level  surface,  upon 
which  the  limb  shall  rest,  than  if  pillows  are  employed.  The 
whole  limb  is  then  gently  raised,  the  thigh  and  leg  being 
flexed,  and  the  seat  of  fracture  carefully  supported,  the  plane, 
having  a  bandage  of  Scultetus  arranged  upon  the  thigh- 
portion  of  it,  slid  underneath,  and  the  limb  now  lowered 


168 


FRACTURES  OF  THE  OS  FEMORIS. 


gradually  down  upon  it.  Care  should  be  taken  that  the 
angle  of  the  knee  corresponds  exactly  with  that  of  the  plane, 
and  that  the  tuherosity  of  the  ischium  presses  well  against 
the  upper  extremity  of  the  apparatus.  The  hand  should  be 
passed  gently  underneath  the  limb,  and  the  cushion  smoothed. 
The  proper  angle  of  the  plane  must  be  determined  by  the 
degree  of  elevation  which  may  be  required  to  make  the  line 
of  the  lower  fragment  level  with  that  of  the  upper,  —  the 
latter,  as  has  been  already  pointed  out,  being  tilted  more  or 
less  upwards  by  the  action  of  the  psoas  magnus  and  iliacus 
internus  muscles.  An  assistant  should  support  the  limb 
while  the  surgeon  confines  upon  the  outer,  upper,  and  inner 
aspects  of  the  thigh  three  splints  of  the  length  of  the  bone, 
by  means  of  the  bandage  of  Scultetus.  The  limb  is  secured 
to  the  plane  by  a  roller,  the  foot  is  attached  to  the  foot-board 
by  the  same  means,  and  the  legs  are  inserted  into  the  holes 
made  for  them.  The  annexed  drawing,  taken  from  Mr. 
Lonsdale's  book,  p.  302,  "represents  the  apparatus  when 
properly  applied.  The  lines  A,  B,  show  the  two  important 
points  that  are  to  be  attended  to ;—  A,  that  the  angle  of  the 


knee  corresponds  with  the  angle  of  the  plane  —  B,  that  the 
tuberosity  of  the  ischium  presses  well  against  the  upper  end." 
(See  fig.  64.) 

Any  disposition  to  the  lateral  angular  deformity,  in  conse- 
quence of  the  glutseus  maximus  muscle  acting  upon  the  upper 


FRACTURES  OF   THE    OS    FEMORIS.  169 

fragment,  may  be  easily  counteracted,  by  directing  the  appa- 
ratus outwardly  from  the  middle  line  of  the  body,  thus  giving 
the  lower  fragment  a  direction  parallel  and  continuous  with 
that  of  the  upper. 

The  chief  modification  of  this  simple  apparatus  is  that  of 
Mr.  Amesbury,  who  contrived  it  to  remedy  the  objections 
which  appeared  to  him  to  be  well-founded  against  the  other : 
these  objections  were,  that  it  allowed  of  motion  of  the  pelvis, 
and  consequently  of  the  upper  fragment,  thereby  disturbing 
the  apposition  of  the  broken  extremities  of  the  bone,  and  that 
it  did  not  allow  of  sufficient  extension  being  made.  It  will  be 
seen,  by  examining  the  double  inclined  plane  above  described, 
that  the  pelvis  is  not  well  confined,  and  that  the  counter- 
extension  is  effected  chiefly  by  the  weight  of  the  body,  aided 
by  the  pressure  of  the  apparatus  against  the  tuberosity  of  the 
ischium,  and  by  the  attachment  of  the  upper  fragment  to  the 
thigh-portion  of  the  plane,  —  while  the  extension  is  made  by 
the  weight  of  the  leg  and  its  confinement,  together  with  that 
of  the  foot,  to  the  lower  plane  and  foot-board. 

Dr.  Spaulding,  of  Buffalo,  has  been  very  successful  in 
treating  these  injuries  by  the  inclined  plane.  He  fixes  the 
pelvis  more  securely,  by  allowing  the  horizontal  portion  of 
the  plane  to  extend  high  up,  so  that  the  tuberosity  of  the 
ischium  shall  rest  upon  it. 

Mr.  Amesbury's  apparatus  is  much  more  complicated.  It 
consists  of  three  parts,  exclusive  of  straight  splints  and  straps : 
one  portion,  a,  corresponds  with  the  thigh,  another,  Z,  with 
the  leg,  and  the  third,  c,  with  the  foot.  (Fig.  65.)  There  are 

FIG.  65. 


two  thigh-pieces  to  each  apparatus,  "  one  is  bevelled  off  at 
the  lower  end  to  the  right;  and  the  other  to  the  left,"  to 
render  the  shape  of  the  upper  part  of  the  plane  conformable 
15 


170  FRACTURES    OF   THE     OS    FE  MORIS. 

to  that  of  the  thigh, — a  perfectly-formed  thigh  being  not 
straight,  but  curving  a  little  inwards  towards  the  knee.  The 
thigh  and  leg-pieces  are  connected  together  by  a  hinge-joint, 
fastened  by  a  pin,  d.  The  foot-board  is  fitted  upon  the  lower 
plane  at  a  right  angle,  and  may  be  fixed  at  a  greater  or  less 
distance  from  the  angle  of  the  two  planes,  by  means  of  a  pin 
or  a  screw.  The  length  of  the  thigh-piece  may  be  adapted 
to  any  limb,  by  means  of  a  sliding  plate  which  is  arranged  at 
its  upper  part,  and  which  may  be  fixed  as  required  by  a  screw. 
The  two  portions  of  the  plane  are  connected  underneath  by  a 
steel  rod,  e,  and  the  angle  of  the  plane  may  be  altered  at 
pleasure,  by  varying  the  point  of  fixation  of  this  rod  to  the 
under  surface  of  the  thigh-piece,  a  rack  being  there  placed 
with  several  projections,  each  of  which  has  a  hole  bored 
through  the  middle,  for  the  purpose  of  receiving  a  bolt,  which 
also  perforates  the  extremity  of  the  rod.  At  the  back  of  the 
sliding  plate,  a  couple  of  bars  are  placed,  which  serve  to 
render  the  plate  more  secure,  and  also  to  confine  the  pelvis- 
strap  which  retains  the  apparatus  in  apposition  with  the 
ischium. 

In  applying  this  apparatus,  it  should  first  be  adapted  to  the 
sound  limb,  in  order  that  the  proper  length  may  be  ascer- 
tained. Then,  the  requisite  angle  having  been  given  to  the 
planes,  and  their  surfaces  smoothly  and  evenly  cushioned  by 
means  of  flannel,  the  broken  limb  should  be  carefully  depo- 
sited upon  the  apparatus,  a  roller  having  been  previously 

FIG.  66. 


applied  from  the  foot  to  the  knee.  The  shoe,  a  (see  fig.  66), 
should  now  be  buckled  over  the  foot  securely,  and  the  pelvis- 
strap  passed  between  the  bars  and  the  plate  of  the  sliding 
portion  of  the  thigh-piece.  The  leg  should  be  confined  to  the 


FRACTURES    OF   THE  OS   FEMORIS.  171 

lower  plane,  by  a  roller,  c?,  and  the  fragments  of  the  femur 
properly  adjusted,  by  extension  and  counter-extension,  and 
retained  in  position  by  three  straight  splints,  one  on  the 
outer,  6,  another  on  the  upper,  /,  and  the  third  on  the  inner 
face  of  the  thigh,  in  which  situations  they  are  secured  by  the 
straps,  #,  </,  <?,  fixed  to  the  back  of  the  apparatus.  "  The 
pelvis-strap,  ^,  should  now  be  carried  round  the  limb  under 
the  strips  of  leather,  on  the  back  of  the  short  splints,  and 
made  to  cross  on  the  outer  side,  and  then  the  buckle-end  with 
the  sliding-pad  should  be  conducted  round  the  pelvis,  and 
made  to  meet  the  other  end  in  front,  where  it  should  be 
buckled." 

When  there  is  much  inflammation,  Mr.  Amesbury  omits 
the  front  splint,  and  applies  evaporating  lotions,  &c.,  &c. 

When  the  apparatus  is  thus  securely  arranged,  it  may  be 
placed  on  its  side,  or  rest  upright.  Mr.  A.,  thinks  that 
"half  way  between  the  side  and  the  heel  is  a  better  position 
for  a  continuance.  I  generally,"  he  continues,  "  place  the 
apparatus  upright,  or  a  very  little  rolled  outwards.  It  is 
maintained  in  either  of  these  positions  by  pillows,  assisted  by 
a  couple  of  tapes,  i,  i,  carried  from  the  lower  end  of  the 
apparatus  to  the  foot  of  the  bed." 

This  apparatus  certainly  seems  to  oifer  much  more  security 
than  the  more  simple  one  before  described,  and  by  it,  accord- 
ing to  the  testimony  of  its  author  and  many  others,  cures  are 
effected  of  fractures  of  the  thigh,  without  apparent  shorten- 
ing of  the  limb. 

Professor  Nathan  R.  Smith,  of  Baltimore,  has  constructed 
a  very  light  and  portable  double  inclined  plane,  for  the  treat- 
ment of  these  injuries,  which  is  believed  to  be  equally  valu- 
able and  efficacious.  A  full  account  of  it  may  be  seen  in 
"  Gredding's  Baltimore  Medical  and  Surgical  Journal,"  vol.  i. 
1833.  It  allows  of  suspension  of  the  limb,  and  a  gentle 
swinging  motion.  The  annexed  figure  will  convey  an  idea  of 
its  construction.  (See  fig.  67.) 

The  inclined  plane  which  seems  to  be  most  in  vogue  in 
England,  is  M'Intyre's,  as  modified  by  Mr.  Liston.  It  con- 
sists of  a  thigh  and  leg  piece  of  sheet  iron,  and  a  foot- board 
of  wood ;  the  former  are  connected  together  by  a  couple  of 
hooks  and  a  screw,  which  is  so  placed  that  the  two  plates  can 
he  set  to  any  angle  at  which  it  may  be  desirable  to  bend  the 


172  FRACTURES    OF    THE    OS    FEMORIS. 

FIG.  67. 


knee ;  and  the  foot-board  is  affixed  in  such  a  manner,  that  it 
may  be  slid  upwards  or  downwards  to  suit  the  length  of  the 
leg,  and  fastened  by  a  side-screw  in  any  position  that  may  be 
wished.  At  the  lower  end  of  the  apparatus  there  is  a  cross 
plate  of  iron,  which  is  so  attached,  that  if  the  foot  be  raised 
or  depressed,  the  plate  will  always  rest  flatwise  on  the  mat- 
trass,  or  a  board  placed  at  the  foot  of  the  bed  for  the  purpose 
of  supporting  it.  (Fig.  68,  taken  from  Fergusson's  book.) 

FIG.  68. 


The  hyponarthecia  of  Mayor  and  Sauter,  is  a  modification 
of  the  same  principle,  —  a  double  inclined  plane,  upon  which 
the  thigh  and  leg  are  confined,  in  the  same  manner  as  is  the 
arm  in  the  hyponarthecia  for  the  upper  extremity ;  as  in  the 
latter  case,  the  apparatus  is  suspended  from  the  bed  or  ceil- 
ing. Those  who  would  see  a  drawing  of  this  apparatus,  are 
referred  to  the  book  of  Mayor,  to  that  of  Cutler,  or  to  that 
of  Dr.  H.  H.  Smith. 

The  only  way  in  which  any  individual  can  form  a  satis- 


FRACTURES    OF    THE    OS    FE  MORIS.  173 

factory  opinion,  as  to  the  real  comparative  efficacy  of  the 
treatment  of  fractures  of  the  thigh  by  position,  is  to  test  it 
for  himself.  The  statements  respecting  it  are  of  the  most 
opposite  kind,  and  by  surgeons  of  equal  eminence, —  among 
whom  are  Amesbury,  Lonsdale,  Cooper,  Bell,  Earle,  in 
favour  of  it,  while  Liston,  Fergusson,  and  most  of  the  con- 
tinental and  American  surgeons  prefer  the  method  by  ex- 
tension. 

This  latter  mode  of  treatment,  as  it  is  now  generally  prac- 
tised, was  proposed  by  Desault.  The  apparatus  employed 
by  him  consisted  of  two  straight  splints  rather  broader  than 
the  antero-posterior  diameter  of  the  limb,  tapering  gradually 
from  the  upper  to  the  lower  end, — one  long  enough  to  extend 
from  the  crest  of  the  ilium  to  four  inches  beyond  the  foot, 
and  the  other  from  the  perineum  to  the  sole  of  the  foot  along 
the  inner  side  of  the  limb ;  near  the  upper  end  of  the  long 
splint  a  hole  was  perforated  for  the  attachment  of  the  coun- 
ter-extending band,  and  a  notch  was  cut  at  the  lower  extrem- 
ity, with  a  perforation  just  above  it,  for  the  securing  of  the 
extending  strap.  The  rest  of  the  apparatus  consisted  of  a 
splint-cloth ;  long  pads  filled  with  chaff,  to  equalize  the  pres- 
sure of  the  splints  along  the  outer  and  inner  faces  of  the 
limb ;  a  counter-extending  band,  to  pass  between  the  pubis 
and  the  upper  part  of  the  thigh,  and  to  be  attached  to  the 
upper  extremity  of  the  long  splint,  and  an  extending  band, 
for  the  purpose  of  firmly  connecting  the  foot  with  the  lower 
end  of  the  same  splint ;  lateral  pressure  was  made  by  means 
of  several  strips  of  muslin,  which  drew  the.  splints  and  the 
pads  firmly  against  the  limb  on  each  side,  while  the  thigh  was 
enveloped  in  a  bandage  of  Scultetus. 

The  objection  to  this  particular  apparatus  is,  that  the  ex- 
tending and  counter-extending  forces  do  not  act  sufficiently 
parallel  with  the  axis  of  the'limb.  This  difficulty  is  obviated 
by  the  very  simple  modification  which  Dr.  Physick  made  of 
the  apparatus  of  Desault.  This  consisted  in  making  the 
outer  splint  long  enough  to  extend  from  the  axilla  to  about 
four  inches  beyond  the  sole  of  the  foot,  and  in  attaching  to 
its  inner  side,  at  about  two  inches  above  its  lower  end,  a 
block,  grooved  on  its  inner  margin,  and  broad  enough  to 
reach  the  line  of  the  middle  of  the  foot  (fig.  69) ;  the  other 
component  parts  of  the  apparatus  are  the  same  as  are  used 


174  FRACTURES    OF    THE    OS    FEMORI?. 

in  Desault's.  The  counter-extending  band  is  best  made  by 
filling  a  narrow  bag  of  muslin,  about  three-fourths 
FIG.  ^9.'  Of  a  yar(j  long,  firmly  with  bran,  or  oat-chaff,  so  as 
to  form  a  cylinder  of  an  inch  in  diameter ;  to  each 
extremity  a  piece  of  strong  tape  should  be  securely 
sewed,  for  the  purpose  of  attaching  the  band  to  the 
upper  extremity  of  the  splint ;  when  this  is  applied, 
a  piece  of  soft  buckskin  should  be  interposed  be- 
tween it  and  the  skin,  as  a  preventive  of  excoriation 
and  chafing.  Extension  is  best  effected  by  means 
of  a  gaiter,  similar  in  shape  to  that  represented  in 
the  annexed  wood-cut  (see  fig.  70);  it  should  be  made 
of  strong  muslin  lined  with  soft  buckskin,  both  to  be 
cut  "bias,"  so  that  the  gaiter  will  set  smoothly  to  the 
ankle ;  stout  tapes  should  be  attached  to  its  lower 
edge,  one  on  each  side,  to  make  traction  upon  it  and 
to  secure  it  to  the  splint,  and  three  or  four  shorter 
tapes  should  be  sewed  to  each  free  margin,  to  tie  the 
gaiter  upon  the  anterior  part  of  the  foot.  Previous 
to  its  application,  the  ankle  should  be  bathed  with 
whiskey,  or  soap-liniment,  or  spirits  of  camphor,  and 
enveloped  smoothly  in  a  pad  of  soft  carded  cotton  ; 
then  the  gaiter  should  be  fitted  nicely  to  the  part, 
and  tied.  The  following  plan  may  be  pursued  in 
arranging  and  applying  this  apparatus,  or  that  of 
Desault :  Place  upon  the  mattrass,  and  in  a  position 
to  correspond  with  the  fractured  limb,  the  splint- 
cloth —  a  piece  of  muslin  about  two  yards  long,  and 
as  wide  as  the  length  of  the  inner  splint, —  and  upon 
this  arrange  the  strips  of  a  bandage  of  Scultetus ; 
then  lay  the  patient  carefully  upon  the  mattrass,  so 
that  the  broken  thigh,  previously  divested  of  clothing, 
shall  repose  upon  the  strips  and  the  splint-cloth  ; 
next  pass  the  perineal  band  under  the  buttock,  and 
tie  the  gaiter  around  the  ankle,  as  before  directed  ; 
the  limb  being  carefully  steadied  by  an  assistant,  roll 
the  splints  in  the  cloth,  commencing  at  the  margins,  leaving 
only  space  enough  between  each  side  of  the  limb  and  the  cor- 
responding splint,  thus  enveloped,  to  admit  of  the  presence 
of  the  junk-bag,  —  the  long  pad  before  spoken  of.  (The 
proper  rolling  up  of  the  splints  requires  some  time  and 


FRACTURES    OF    THE    OS    FEMORIS.  175 

trouble  —  they  should  be  tightly  wrapped,  so  that  when 
pressure  is  used  laterally  upon 
the  limb,  they  may  not  slip,  and 
thus  leave  a  larger  space  be- 
tween them  and  the  leg  than  is 
compatible  with  the  accomplish- 
ment of  one  of  the  objects  for 
which  they  are  employed,  viz., 
the  exercise  of  an  equable  arid 
firm  compression  upon  the  limb, 
by  the  aid  of  the  junk-bags.) 
The  splints  being  thus  prepared  for  use,  extension  and  counter- 
extension  should  be  made  by  assistants,  the  one  grasping  the 
foot  and  ankle,  and  the  other  fixing  the  pelvis  —  by  one  hand 
passed  between  the  thigh  and  the  pubis  and  ischium,  and  the 
other  on  the  outside  of  the  hip  —  while  the  surgeon  coaptates 
the  fragments,  and  adjusts  the  shape  of  the  thigh ;  he  then 
arranges  the  bandage  of  Scultetus,  and  afterwards  presses 
the  junk-bags  and  the  splints  firmly  against  the  sides  of  the 
limb ;  the  counter-extending  and  extending  bands  should  now 
be  tightly  secured  to  their  corresponding  extremities  of  the 
long  splint, — the  tapes  attached  to  the  gaiter  passing  over  the 
grooved  margin  of  the  block,  before  described.  To  secure 
the  limb  in  this  adjustment,  three  or  four  strips  of  muslin 
should  be  passed  underneath  the  apparatus-,  at  intervals  along 
the  limb,  and  tied  across,  the  knot  being  made  upon  the  edge 
of  one  of  the  splints,  to  prevent  it  slipping ;  and  a  broad  band 
should  likewise  confine  the  upper  part  of  the  long  splint  to 
the  side.  It  is  sometimes  advisable  to  give  additional  support 
to  the  foot,  by  tying  a  strip  of  muslin  around  it,  and  then  pin- 
ning the  ends  to  the  splint-cloth.  An  arched  frame  of  wire, 
or  of  hoop,  should  be  placed  over  the  foot,  to  protect  it  from 
the  pressure  of  the  bed-clothes. 

The  limb  should  be  placed  out  from  the  axis  of  the  body, 
particularly  in  those  cases  where  the  fracture  is  at  such  a 
point  as  that  the  glutseus  maximus  muscle  will  draw  the  upper 
fragment  of  bone  outwards. 

It  is  well  to  use  the  bandage  of  Scultetus  during  the  first 
few  days  after  the  injury,  since  it  makes  gentle  and  equable 
pressure  upon  the  muscles  of  the  thigh,  and  assists  some- 
what to  keep  the  fragments  of  the  bone  in  apposition ;  after 


\ 


FRACTURES  OF  THE  OS  FE  MORIS. 

the  first  week  or  ten  days,  however,  it  is  probably  as  well,  or 
better,  to  remove  it,  leaving  the  thigh  exposed  to  the  eye  of 
the  surgeon. 

Cold  lotions  should  be  applied  at  any  time,  as  they  may  be 
called  for  by  the  condition  of  the  soft  parts ;  anodyne  lini- 
ments are  sometimes  of  service  in  allaying  muscular  irritabi- 
lity, and  in  alleviating  pain  in  the  limb. 

Very  excellent  cures  may  be  effected,  undoubtedly,  by  the 
use  of  this  apparatus ;  but  it  is  one  which  demands,  in  its 
employment,  the  greatest  care  and  attention  on  the  part  of 
the  attendant.  There  are  some  points  to  which  the  author 
would  call  particular  notice :  —  the  accidents  chiefly  to  be 
feared,  as  directly  connected  with  the  use  of  this  splint,  are, 
excoriations  and  sloughs  upon  the  heel,  on  the  inner  side  of 
the  knee,  at  the  prominence  of  the  innqr  condyle  of  the 
femur  and  the  corresponding  point  of  the  tibia,  and  in  the 
perineum.  These  are  not  necessary  accompaniments  of  the 
mode  of  treatment  now  under  consideration,  and  with  proper 
care  they  will  never  occur ;  but  without  great  watchfulness 
they  are  exceedingly  likely  to  happen ;  they  may  be  avoided 
in  this  way: — 

The  gaiter  should  be  unbound  daily,  so  long  as  it  is  worn, 
and  the  instep,  ankles,  and  heel  carefully  examined.  During 
the  first' week,  or  ten  days,  the  gaiter  should  be  loosened 
every  morning  and  evening,  and  these  parts  bathed  with 
whiskey,  or  soap-liniment ;  this  may  be  done  without  in  the 
slightest  degree  deranging  the  fragments  of  bone,  simply  by 
turning  up  the  lower  ends  of  the  junk-bags,  so  as  to  give 
room  for  the  introduction  of  the  hand  between  the  splint  and 
the  foot,  —  the  strips  which  maintain  the  lateral  pressure 
being  securely  tightened.  The  inner  side  of  the  knee  should 
be  gently  rubbed  in  the  same  way,  and  a  little  indentation 
should  be  made  in  the  junk-bag,  corresponding  with  the  bony- 
prominences  of  the  femur  and  tibia  at  this  point.  The  peri- 
neal  band  should  be  loosened  daily,  —  the  limb  being  sup- 
ported the  while  by  an  assistant,  and  the  lateral  compression 
maintained,  —  and  the  parts  upon  which  it  presses  bathed,  as* 
the  others.  Whenever  the  apparatus  is  thus  re-adjusted,  re- 
newed extension  and  counter-extension  should  be  made,  and 
in  order  that  this  may  be  persevered  in  until  the  end  of  the 
treatment,  it  is  highly  necessary  that  the  splints  shall  be  so 


FRACTURES    OF    THE    OS    FEMORIS.  17T 

closely  wrapped  in  the  cloth,  and  shall  approach  the  limb,  on 
each  side,  so  nearly,  as  that  firm  lateral  pressure  may  be  kept 
up,  and  thus  the  strain  upon  the  foot  and  perineum  rendered 
very  supportable. 

It  is  advisable,  oftentimes,  to  vary  the  means  by  which  the 
extension  and  counter-extension  are  effected.  Thus,  after 
having  used  a  perineal  band  of  the  dimensions  and  form 
above  recommended,  let  one  be  substituted  flattened  in  shape 
and  broader,  so  as  to  act  upon  a  larger  surface,  and  thus 
relieve  that  part  which  has  been  already  pressed  upon.  So 
with  regard  to  the  gaiter, — it  will  occasionally,  perhaps,  be 
well  to  substitute  for  this  a  handkerchief  folded  into  the 
cravat-shape,  and  applied  so  as  to  press  upon  the  instep  and 
the  point  of  the  heel,  the  tails  passing  from  the  sides  of  the 
foot,  parallel  with  the 
axis  of  the  limb,  and  FlG- 

reaching  to  the  ex- 
tremity of  the  long 
splint  upon  which 
they  are  tied.  (See 
fig.  71.)  Another 
mode  of  making  ex- 
tension is  by  means 
of  adhesive  plaster, 
as  follows : — Cut  two  very  long  strips,  of  an  inch,  or  more, 
in  width,  and  apply  them  to  the  leg,  commencing  at  a  point 
halfway  between  the  foot  arid  the  knee,  descending  spirally  to 
the  side  of  the  foot,  one  on  each  side :  then,  when  adhesion 
between  the  strip  and  the  integuments  has  become  firm, 
attach  the  strips  to  the.  extremity  of  the  long  splint,  as  by 
the  other  method.  This  plan  was  first  employed  by  Dr. 
E.  Wallace,  of  this  city,  while  Resident  Surgeon  at  the  Hos- 
pital ;  he  used  it  as  a  substitute  for  the  gaiter,  which  had 
produced  excoriation  just  above  the  heel;  the  author  had  the 
pleasure  of  witnessing  the  complete  success  which  attended 
the  operation  of  this  novel  extending  band,  both  in  the  in- 
stance in  which  it  was  first  tried  and  in  several  other  cases, 
and  he  would  recommend  it  highly,  as  being  perfectly  secure 
and  efficacious.  It  may  be  proper  to  make  use  of  a  few  turn? 
of  a  roller,  or  of  a  bandage  of  Scultetus,  to  compress  the 
adhesive  strips  against  the  leg,  but  this  is  scarcely  called  for, 


178  FRACTURES    OF    THE    OS    FEMORIS. 

since  the  junk-bags  exercise  sufficient  pressure  of  them- 
selves.1 

If  there  is  any  disposition  to  excoriation  or  sloughing  upon 
the  points  of  the  malleoli,  pressure  should  be  taken  off  from 
them,  by  not  allowing  the  junk-bags  to  extend  so  low  down. 
The  same  accident  may  be  prevented  from  occurring  upon 
the  point  of  the  heel  by  placing  a  cushion  just  above  it, 
under  the  leg,  so  that  the  weight  of  the  limb  shall  not  fall 
upon  this  point.  The  same  simple  method  may  be  resorted 
to  when  a  similar  accident  threatens  the  hips  or  back,  —  a 
judicious  arrangement  of  pillows  will  often  obviate  much  mis- 
chief, aided  also  by  stimulating  liniments  applied  to  the  parts. 
When,  in  spite  of  these  precautions,  sloughing  does  occur  — 
as  it  sometimes  will  in  old  persons,  or  in  those  of  lax  fibre, — 
all  pressure  should  be  at  once  withdrawn  from  the  affected 
surface,  and  the  separation  of  the  dead  tissue  aided  by  the 
application  of  poultices ;  afterwards  stimulating  washes 
should  be  used,  among  the  best  of  which  is  Labarraque's 
solution  of  the  chloride  of  soda,  diluted  with  three  or  four 
parts  of  water,  and  applied  to  the  ulcer  upon  rags,  or,  if  the 
slough  has  extended  beneath  the  skin,  injected  from  a 
syringe. 

There  is  one  objection  to  the  employment  of  this  apparatus 
of  Desault  and  Physick  in  the  treatment  of  fractures  of  the 
thigh,  occurring  particularly  in  the  upper  third  of  the  shaft 
—  (and  the  same  objection  is  applicable  to  the  treatment  by 
extension  in  the  straight  position,  generally) :  it  is  sometimes 
impossible  to  counteract,  by  it,  the  deformity  which  arises 
from  the  powerful  contraction  of  the  iliacus  internus  and  psoas 
magnus  muscles,  which  tilt  up  the  lower  end  of  the  upper 

1  I  am  greatly  indebted  to  the  kindness  of  Dr.  Gross,  the  distinguished 
professor  of  surgery  at  Louisville,  for  the  knowledge  of  the  fact  that  this 
application  of  adhesive  plaster  was  originally  made  more  than  twenty  years 
ago,  by  Dr.  Swift,  of  Easton. 

In  his  treatise  on  "  the  Anatomy,  Physiology,  and  Diseases  of  the  Bones 
and  Joints"  (Philadelphia,  1830,  p.  50),  Dr.  Gross  points  out  the  reasons 
which  led  Dr.  Swift  to  suggest  this  means  of  making  extension;  they  are, 
precisely  those  which  induced  Dr.  Wallace  to  resort  to  this  expedient.  Dr. 
Wallace,  I  am  sure,  had  no  knowledge  that  any  one  had  previously  recom- 
mended or  employed  the  adhesive  plaster  for  this  purpose. 

Latterly,  the  employment  of  adhesive  strips  has  been  very  much  extended 
\o  the  treatment  of  many  other  fractures ;  as  by  Dr.  Crosby,  to  fracture  of 
the  clavicle.  (New  York  Journal  of  Medicine,  1851.) 


FRACTURES    OF    THE    OS    FE  MORIS.  179 

fragment.  When  this  action  is  but  slight  it  may  be  over- 
come, gradually,  by  compression  with  a  splint  bound  upon  the 
anterior  face  of  the  thigh,  or  by  a  compress,  or,  finally,  by  a 
little  elevation  given  to  the  lower  fragment  by  means  of  a 
folded  sheet  placed  beneath  the  thigh,  at  this  point.  But  in 
very  athletic  patients  the  muscles  in  question  may  contract 
too  powerfully,  and  then  these  means  will  fail ;  if  the  straight 
splints  are  retained,  a  permanent  deformity  will  ensue  and 
the  limb  will  be  always  weak,  in  consequence  of  the  imper- 
fect apposition  of  the  fragments.  In  such  cases  as  these,  the 
double  inclined  plane  should  be  substituted  for  the  other 
apparatus. 

The  apparatus  of  Desault,  improved  as  above  described,  is, 
we  think,  the  best  which  has  yet  been  contrived  for  the  treat- 
ment of  fractures  of  the  thigh,  in  the  extended  position. 

There  are  several  other  modifications  of  Desault's  appara- 
tus, less  simple  than  the  one  which  we  have  explained. 

The  late  Dr,  Hartshorne,  of  this  city,  invented  one  in 
which  the  long  and  the  short  splints  are  connected  together 
by  a  transverse  piece,  through  which  a  long  wooden  screw 
passes,  having  a  foot-board  attached  to  it. 

Dr.  T.  H.  Bache,  lately  resident  Surgeon  to  the  Pennsyl- 
vania Hospital,  has  modified  Physick's  apparatus  as  follows : 
A  long,  narrow  fenestrum  is  cut  in  the  outer  splint,  extend- 
ing upwards  from  near  its  lower  extremity ;  in  this  slides 
an  iron  arm,  capable  of  being  firmly  fixed  by  screw-clamps  at 
any  point,  so  as  virtually  to  lengthen  or  shorten  the  splint  in 
adaptation  to  limbs  of  different  length ;  through  this  arm 
passes  a  long  screw,  its  axis  being  continuous  with  that  of  the 
limb  when  placed  between  the  two  splints,  and  to  the  upper 
or  proximal  end  of  the  screw  is  attached  a  transverse  piece 
of  iron,  having  a  hole  pierced  through  each  extremity.  To 
apply  this  apparatus,  the  limb  is  placed  between  the  two 
splints,  and  a  counter-extending  band  and  junk-bags  are 
arranged  just  as  in  Physick's  method  ;  but  the  extending  tapes 
or  adhesive  strips  are  secured  to  the  transverse  iron  plate 
last  spoken  of,  so  that  the  elongation  of  the  limb  is  accom- 
plished by  acting  upon  the  screw  which  passes  through  the 
arm  that  is  connected  to  the  outer  splint.  The  arrangement 
is  very  neat,  and  the  apparatus  light  and  strong.  Its  action 
is  very  well  spoken  of  by  the  gentlemen  who  are  attached  to 


180  FRACTURES    OP    THE    OS    FEMORIS. 

the  Pennsylvania  Hospital ;  it  is  believed  by  them  that  it 
effects  elongation  of  the  shortened  limb  more  gradually  than 
Physick's  splint,  and  that  it  enables  the  surgeon  to  judge 
accurately  whether  or  not  he  is  really  gaining  in  this 
particular. 

I  must  confess  that  I  should  prefer  the  simpler  apparatus 
of  Dr.  Physick.  From  having  seen  Dr.  Bache's  splint  in  use 
at  the  Hospital  in  two  or  three  cases  of  fractured  thigh,  my 
impression  is  that  the  foot  is  not  as  securely  and  steadily  held 
by  this  as  by  the  other ;  and  it  appears  to  me  that  to  make 
extension  by  the  screw,  rather  than  by  the  hands  directly  ap- 
plied to  the  limb,  is  more  likely  to  endanger  excoriation  of 
the  foot.  The  stretching  of  the  extending  strips  or  tapes, 
under  the  force  constantly  acting  upon  them,  will  readily  de- 
ceive any  one  who  trusts  to  the  mere  operation  of  the  screw 
to  inform  him  as  to  the  improvement  in  the  length  of  the 
limb.  Moreover,  the  simplicity  of  Physick's  apparatus  is  in 
itself  an  advantage  and  a  recommendation.  Perhaps  the 
splint  of  Dr.  Bache  might  be  improved  by  attaching  to  the 
screw  a  foot-piece,  to  which  the  foot  should  be  immediately 
secured,  instead  of  having  a  simple  transverse  piece. 

Boyer's  apparatus  is  composed  of  a  long  splint  for  the  ex- 
ternal side  of  the  limb,  with  a  movable  foot-board  connected 
therewith ;  of  two  straight  splints  for  the  anterior  and  inner 
faces  of  the  limb;  a  belt  enclosing  the  upper  part  of 'the 
thigh  and  the  groin,  and  giving  a  "point  d'appui"  to  the 
upper  extremity  of  the  outer  splint ;  straps  to  secure  the  foot 
to  the  foot-board ;  cushions,  and  tapes  to  confine  the  appara- 
tus upon  the  limb.  The  outer  splint  is  the  only  complicated 
part  of  the  apparatus.  It  is  about  four  feet  long  and  as 
many  inches  in  width ;  from  its  lower  extremity  upwards, 
along  about  half  its  length,  runs  a  groove  in  which  a  screw 
plays ;  the  upper  end  of  the  screw  turns  upon  an  iron  plate, 
while  the  other  extremity,  at  the  end  of  the  splint,  has  a  key 
attached  to  it,  by  which  it  is  made  to  revolve.  A  foot-piece, 
made  of  iron,  and  padded,  is  connected  with  the  screw,  upon 
the  inner  side  of  the  splint,  and  is  moved  nearer  to,  or  far- 
ther from,  the  lower  extremity  of  the  latter  by  revolutions 
of  the  screw,  so  as  to  make  the  necessary  extension,  while 
the  upper  end  of  the  splint  fits  into  a  little  pouch  upon  the 
thigh-strap,  thus  effecting  the  counter-extension :  the  foot- 


FRACTURES    OF    THE    OS    FEMORIS. 


181 


piece  has  two  legs  upon  which  it  rests.  In  the  application 
of  this  apparatus  the  foot  is  attached  to  the  iron  plate ;  the 
upper  end  of  the  splint  is  inserted  into  the  pocket  of  the 
thigh-belt,  which  has  been  previously  passed  around  the 
upper  part  of  the  thigh  and  groin ;  a  long  pad  protects  the 
limb  from  contact  with  the  outer  splint,  and  equalizes  the 
pressure  from  it ;  then,  after  the  reduction  of  the  fracture, 
the  inner  and  anterior  splints,  well  padded,  are  placed  upon 
the  thigh,  and  the  whole  is  secured  by  means  of  several 
bands,  as  shown  in  the  figure.  (See  fig.  72.)  As  much  ex- 
tension as  the  surgeon  thinks  necessary  is  made  by  turning 
the  screw,  thus  drawing  down  the  foot,  and  with  it,  of  course, 
the  lower  fragment  of  the  broken  femur. 


FIG.  72. 


Mr.  Listen  recommends  the  employment  of  a  single 
straight  splint  of  deal-board,  long  enough  to  extend  from 
opposite  the  nipple  to  three  or  four  inches  beyond  the  foot ; 
near  its  upper  end  two  holes  are  bored,  and  the  lower  extre- 
mity is  notched,  while  just  above  the  latter  is  a  perforation 
large  enough  to  accommodate  the  malleolus ;  the  splint  is  co- 
vered on  its  inner, face  by  a  cushion.  The  leg  is  bandaged 

Fro.  73. 


from  the  toes  nearly  to  the  seat  of  fracture,  before  the  splint 
is  applied :   then  the  fracture  is  reduced,  and  the  perineal 
16 


182 


FRACTURES  OF  THE  OS  FE  MORIS. 


FIG.  74. 


band — made  as  for  Desault's  apparatus — is  tied  to  the  upper 
end  of  the  splint,  to  which  the  whole  limb  and  the  side  of  the 
body  are  now  confined  by  means  of  a  roller,  —  several  turns 
being  passed  around  the  foot,  and  gaining  support  from  the 
notches  made  in  the  lower  end  of  the  splint.  (Liston's  Pract. 
Surg.)  (See  fig.  73.) 

Drs.  Kimball  and  Sanborn,  of  Lowell,  Mass.,  have  contrived 
a  single  splint  for  the  treatment  of  fractures 
of  the  thigh,  which  is  figured  in  Miller's  Prac- 
tice of  Surgery.  (Fig.  74.) 

It  extends  from  the  axilla  to  below  the  foot, 
but  is  so  contrived  as  to  be  capable  of  being 
lengthened  at  each  extremity.  The  upper  end 
terminates  in  the  manner  of  a  crutch;  the 
lower  has  a  sliding  bar  fitted  to  it,  upon  which 
a  transverse  arm  is  secured  at  right-angles. 
In  using  this  splint,  "  two  long  pieces  of  strong' 
adhesive  strap  are  applied,  one  on  each  side 
of  the  limb,  extending  from  above  the  knee  to 
the  ankle,  and  these  are  secured  by  a  roller. 
The  end  of  each  strap  is  uncovered  with  adhe- 
sive matter,  and  hangs  loose  from  the  foot. 
The  ends  of  each  strap  are  secured  to  the 
cross-bar  at  the  splint's  extremity,  and  the 
limb  is  made  one  with  the  splint  in  the  ordi- 
nary way.  By  turning  the  screw,  the  cross- 
bar is  moved  up  or  down,  at  will,  and  extension 
consequently  is  regulated  with  both  accuracy 
and  power.  The  perineal  band  is  employed 
besides,  but  should  its  pressure  prove  at  any 
time  galling,  it  may  be  temporarily  discon- 
tinued with  safety,  the  crutch  of  the  splint 
being  moved  up  into  the  axilla,  to  supply  its 
place."  (Miller's  Practice,  p.  652.) 

We  do  not  see  that  the  screw-extension 
power  is  of  much  advantage,  and  we  can  by 
no  means  advise  any  one  to  dispense  with  the 
perineal  counter-extending  band,  because  the 
axilla  does  not  offer  a  fixed  point  of  resistance. 
And,  moreover,  it  is  impossible  to  preserve  the  proper  shape 
and  direction  of  the  limb  if  only  one  splint  is  used. 


FRACTURES  OF  THE  OS  FEMORIS. 


183 


The  same  objection  is  applicable  to  the  original  splint  of 
Hagedorn,  which  consists  of  a  single  long  splint  and  a  foot- 
board, the  latter  being  broad  enough  to  support  both  feet, 
and  moving  up  and  down,  but  capable  of  being  secured  at  any 
point  upon  the  splint. 

Dr.  Gibson,  Professor  of  Surgery  in  the  University  of 
Pennsylvania,  has  introduced  a  modification  of  Hagedorn's 
apparatus,  which  he  thus  describes  —  ("  Institutes  and  Prac- 
tice of  Surgery,"  vol.  i.): — u  This  method  consists  in  extend- 
ing the  patient's  limbs  upon  a  mattrass,  and  confining  both 
feet,  by  gaiters,  or  a  handkerchief,  to  a  footboard  which  is 
firmly  supported  upon  the  ends  of  two  splints  passed  through 
mortices  near  its  edges.  These  splints  extend  from  the  arm- 
pit, where  they  are  padded  like  the  head  of  a  crutch,  along 
each  side  of  the  body,  thigh  and  leg,  beyond  the  foot,  and, 
being  well  stuffed  on  their  inner  surfaces  to  prevent  irritation, 
are  confined  by  six  or  eight  broad  tapes  or  bandages  passed 
around  the  limbs,  pelvis,  chest,  &c.  (See  fig.  75.) 

"  The  principle  upon  which  extension  and  counter-extension 
are  effected  by  this  contrivance,  will  instantly  be  understood. 
The  sound  limb  being  extended,  serves  as  a  splint  to  the  bro- 

FIG.  75. 


ken  one.  Counter-extension  then  is  made  upon  the  acetabu- 
lum  of  the  sound  side,  and  extension  upon  the  ankle  of  the 
injured  limb,  which,*  so  long  as  the  two  feet  are  kept  on  the 
same  level,  cannot  be  shortened,  provided  rotation  of  the 
pelvis  be  prevented.  This  purpose  is  answered  by  extending 
the  splints  to  the  arm-pits,  and  not  with  a  view,  as  might  be 
supposed,  of  producing  counter-extension  from  these  points. 
Finding  that  the  patient,  in  the  original  machine  of  Hage- 
dorn, could  incline  the  pelvis  towards  the  affected  side,  and 


184  FRACTURES    OF    THE    OS    FE  MORIS. 

thereby  shorten  the  limb,  by  causing  the  superior  fragment 
to  descend  and  overlap  the  inferior,  the  additional  splint 
was  added,  and  has  been  found  to  answer  completely  the  end 
designed." 

During  my  residence  in  the  Pennsylvania  Hospital,  I  had 
the  opportunity  of  testing  the  efficacy  of  this  apparatus,  in 
two  cases  of  fracture  of  the  thigh, — one  in  a  child,  the  other 
in  an  adult.  In  both  instances,  the  result  was  as  satisfactory 
as  I  have  ever  seen  to  follow  the  employment  of  any  other 
method  :  I  was  led  to  make  use  of  this  apparatus,  because  the 
skin  about  the  ankle  and  perineum  of  the  child  was  so  very 
tender,  as  to  render  the  pressure  upon  these  parts,  from  the 
gaiter  and  counter-extending  band  of  Desault's  apparatus, 
insupportable,  and,  moreover,  he  was  not  sufficiently  restrained 
by  this  last-mentioned  apparatus ;  —  and  because,  in  the  in- 
stance of  the  man,  the  whole  instep  was  much  bruised  by  the 
same  fall  which  caused  the  fracture  of  the  thigh.  The  plan 
which  I  adopted  was  the  following :  —  A  straight  splint  was 
first  confined  to  the  under  surface  of  the  sound  limb,  to  pre- 
vent flexion  of  the  knee ;  the  splints  were  then  placed  on 
each  side  of  the  patient ;  the  sound  foot  was  secured  to  the 
foot-board ;  long  pads  protected  the  outer  sides  of  the  limbs 
from  contact  with  the  boards  ;  the  fractured  thigh  was  brought 
to  the  same  length  as  the  other,  and  the  foot  bandaged  to 
the  foot-board;  a  firm  junk-bag  was  now  inserted  between  the 
limbs  along  their  whole  length,  so  that  the  injured  limb  should 
be  supported  at  every  point  by  the  other,  and  several  wide 
strips  of  muslin  were  made  to  enclose  in  their  grasp  each 
thigh,  with  its  splint  and  the  junk-bag ;  finally,  the  splints 
above  the  pelvis  were  pressed  against  the  patient's  sides,  by 
means  of  muslin  bands,  and  in  the  same  manner  lateral 
pressure  was  effected  upon  the  whole  apparatus. 

The  management  of  this  apparatus  requires  great  atten- 
tion ;  its  confinement  is  very  irksome  to  the  patient,  as  it 
;  imprisons  both  limbs.  It  is  particularly  troublesome,  when 
he  has  an  evacuation  of  the  bowels  to  effect,  because  he  can- 
not assist  himself,- nor  the  attendant,  with  the  sound  leg; 
when  it  is  employed,  therefore,  a  clinical  frame,  such  as  has 
been  described,  should  be  used  instead  of  an  ordinary  frac- 
ture-bed, or  the  fracture-bed  herein  described,  will  be  found 
serviceable  and  convenient. 


FRACTURES    OF    THE    OS    FEMORIS.  185 

The  same  care  as  when  the  other  splints  are  resorted  to, 
i.j  requisite,  with  regard  to  the  prevention  of  injury  to  the 
parts  of  the  integuments  pressed  upon,  as  the  heel,  ankles, 
hips,  &c. 

It  is  proper  to  mention  that,  in  the  man  upon  whom  this 
apparatus  of  Dr.  Gibson  was  tried,  the  fracture  was  at  the 
lower  third  of  the  femur,  and  that  the  thigh  was  not  a  very 
muscular  one.  Whether  a  sufficient  degree  of  extension  can 
be  accomplished  by  it,  to  maintain  in  coaptation  the  frag- 
ments of  a  thigh-bone,  when  the  muscles  of  the  limb  are  fully 
developed,  and  when  the  fracture  is  higher  up,  within  the 
operation  of  the  glutgeus  muscle,  the  author  cannot  affirm ;  he 
has  a  sufficiently  good  opinion  of  the  apparatus,  however,  to 
be  induced  to  use  it  again. 

In  fractures  of  the  shaft  occurring  in  young  children,  the 
method  recommended  by  Mr.  Listen,  as  before  described, 
with  the  addition  of  curved  splints  for  the  anterior,  posterior, 
and  inner  surfaces  of  the  thigh,  is  the  most  convenient  and 
the  best  plan  of  treatment.  The  naturally  slightly  curved 
shape  of  the  bone  should  be  recollected,  and  this  conforma- 
tion should  be  secured  by  the  proper  use  of  compresses. 

2. .  For  fractures  of  the  thigh  at  its  upper  extremity. 

The  general  principles  of  treatment  in  these  cases  are  the 
same  as  when  the  shaft  is  broken  ;  but  there  are  some  ana- 
tomical and  physiological  peculiarities  of  the  pelvic  extremity 
of  the  os  femoris,  which  require  corresponding  modifications 
of  treatment,  when  this  part  of  the  bone  is  ruptured. 

When  the  fracture  occurs  within  the  capsular  ligament  of 
the  joint,  bony  union,  according  to  the  best  authorities,  is  at 
least  exceedingly  improbable,  though  not  impossible.  (See 
Sir  A.  Cooper,  Cruvelhier,  R.  W.  Smith,  &c.)  The  acci- 
dent happens,  moreover,  for  the  most  part,  to  persons  ad- 
vanced in  life  and  incapable  of  supporting  long  confinement 
in  bed  in  any  one  position.  Concerning  the  treatment  of 
these  cases,  Sir  A.  Cooper  makes  the  following  remarks :  — 
"  I  would  prefer  a  ligamentous  union  to  the  confinement  and 
danger  of  bony  union,  in  regard  to  the  health  and  life  of  the 
person,  and,  as  I  believe,  to  the  subsequent  use  of  the  joint. 
Baffled  in  our  various  attempts  to  cure  these  cases,  and  find- 
ing the  life  of  the  patient  occasionally  sacrificed  under  the 
trials  made  to  procure  bony  union,  I  should,  if  I  sustained 
16  * 


186  FRACTURES    OF    THE    OS    FEMORIS. 

this  accident  in  my  own  person,  direct  that  a  pillow  should  "be 
placed  under  the  limb  throughout  its  length;  that  another 
should  be  rolled  up  under  the  knee,  and  that  the  limb  should 
be  thus  extended  until  the  inflammation  and  pain  had  sub- 
sided. I  should  then  daily  rise  and  sit  in  a  high  chair,  to 
prevent  a  degree  of  flexion  which  would  be  painful ;  and, 
walking  with  crutches,  bear  gently  on  the  foot  at  first,  then, 
gradually  more  and  more,  until  the  ligament  of  union  had 
become  thickened,  and  the  muscles  increased  in  their  power. 
A  high-heeled  shoe  should  be  next  worn,  by  which  the  halt 
would  be  much  diminished.  Our  hospital  patients,  treated 
after  this  manner,  are  allowed  in  a  few  weeks  to  walk  with 
crutches ;  after  a  time  a  stick  is  substituted,  and  in  a  few 
months  they  are  able  to  use  the  limb  without  any  adventitious 
support."  (Sir  A.  Cooper,  op.  cit.,  p.  142.) 

When  the  solution  of  continuity  has  occurred  partly  within 
and  partly  without  the  capsular  ligament,  or  through  the 
great  trochanter,  the  displacement  is  less,  and  it  is  more 
easily  obviated.  The  limb  should  be  kept  in  the  extended 
position,  by  any  of  the  methods  which  have  been  described, 
and  the  outer  splint  should  be  pretty  firmly  pressed  against 
the  trochanter  and  the  side  of  the  body  by  a  circular  band- 
age. The  apparatus  of  Dr.  Gibson  would  answer  admirably 
in  these  cases. 

If  the  trochanter  major  be  merely  severed  from  the  root 
of  the  neck,  the  axis  of  the  bone  not  being  involved,  there  is 
no  shortening  of  the  limb,  and  the  treatment  of  the  accident 
is  very  simple.  The  patient  should  be  kept  upon  his  back, 
with  the  limb  in  the  extended  position,  and  rendered  in- 
capable of  flexion  at  the  knee  and  thigh  by  means  of  a  well- 
padded  splint,  extending  from  above  the  tuberosity  of  the 
ischium  to  near  the  heel,  and  secured  thus  by  rollers ;  in 
addition,  a  broad  band  should  be  passed  around  the  pelvis,  to 
compress  the  fragment  of  the  trochanter  upon  its  place. 

The  annexed  wood-cut  illustrates  a  method  pursued  by  Sir 
A.  Cooper,  in  the  treatment  of  this  injury.  The  patient  is 
lying  upon  a  fracture-mattrass,  to  the  foot  of  which  is  attached 
an  upright  support  for  the  sole  of  the  foot;  a  broad  band 
grasps  the  trochanter  and  presses  it  upon  its  natural  seat. 
(See  fig.  76.) 

3.  For  fractures  at  the  lower  extremity  of  the  femur. 


FRACTURES    OF    THE    OS    FE  MORIS.  187 

FIG.  76 


The  thigh-bone  may  be  broken  transversely  just  above  the 
condyles,  or  obliquely,  or  the  fracture  may  extend  through 
the  condyloid  expansion  into  the  joint. 

In  the  first  case,  there  is  oftentimes  no  displacement,  or  if 
the  axis  of  the  limb  has  been  deranged,  the  fragments,  after 
reduction,  are  easily  retained  in  apposition  by  lateral  com- 
pression and  rest  in  the  extended  position. 

When,  however,  the  fracture  extends  obliquely  from  behind 
forwards  and  downwards,  as  is  usually  its  line  of  direction,  or 
even  from  before  backwards  and  downwards,  the  powerful  mus- 
cles which  descend  from  the  pelvis  act  with  great  energy  upon 
the  lower  fragment,  and  draw  it  upwards,  leaving  the  ex- 
tremity of  the  upper  fragment,  in  the  first-mentioned  variety, 
projecting  anteriorly  and  penetrating  the  rectus  muscle, 
sometimes  perforating  the  integuments  even.  The  treatment 
of  this  injury  consists  in  keeping  up  strong  extension  and 
counter-extension  in  the  straight  position,  and  in  making  as 
firm  compression  upon  the  fragments,  when  reduced,  as  the 
condition  of  the  parts  will  allow,  aided  generally  by  evapora- 
ting lotions,  leeching,  &c.,  &c.  After  the  lapse  of  three  or 
four  weeks,  passive  motion  should  be  commenced  cautiously 
and  persisted  in.  (Sir  A.  Cooper.) 

Others  advise  that  the  limb  should  be  secured  upon  the 
double  inclined  plane,  the  foot  being  well  supported.  They 
urge  in  favour  of  this  position,  that  it  relaxes  the  muscles 
which  act  so  powerfully  upon  the  lower  fragment,  and  thus 
renders  sufficient  a  less  degree  of  extension  upon  the  inflamed 
joint,  while  the  mere  pressure  of  the  under  surface  of  the 
limb  upon  the  plane  counteracts  in  a  great  measure  the 
retraction  of  the  lower  fragment. 


188  FRACTURES    OF    THE    OS    FE  MORIS. 

A  strong  argument  in  favour  of  the  straight  position  is 
that,  if  anchylosis  should  occur,  the  limb  is  in  a  much 
more  desirable  position  than  if  the  double  inclined  plane  is 
employed. 

When  one  of  the  condyles  is  separated  from  its  connexion 
with  the  lower  portion  of  the  femur,  the  extended  position  is 
certainly  the  most  favourable  one  for  the  relief  of  the  acci- 
dent. A  piece  of  pasteboard,  large  enough  to  inclose  the 
posterior  two-thirds  of  the  joint,  and  notched  along  its  mar- 
gins to  enable  it  to  adapt  itself  better  to  the  form  of  the  part, 
should  be  softened  in  hot  water  and  then  moulded  about  the 
posterior  face  of  the  knee,  and  secured  thus  by  means  of  a 
roller ;  Desault's  apparatus,  or  a  single  straight  splint  for  the 
under  surface  of  the  limb,  will  complete  the  necessary  con- 
fining means. 

4.  For  compound  fractures  of  the  thigh,  the  same  general 
principles  of  treatment  exist  as  for  the  simple :  the  accident 
should  be  converted  into  a  simple  fracture,  if  practicable,  by 
immediate  closure  of  the  wound  ;  and  during  the  whole  pro- 
gress of  the  case,  the  natural  conformation  and  length  of  the 
limb  should  be  preserved,  as  far  as  possible.  It  must  be 
borne  in  mind,  however,  that  some  degree  of  shortening  will 
occur  almost  of  necessity,  in  consequence  of  necrosis  of  the 
broken  extremities  of  the  bone,  and  because,  from  the  nature 
of  the  injury,  the  same  degree  of  extension  and  of  lateral 
compression  cannot  be  maintained  as  in  cases  of  simple 
fracture. 

The  limb  may  be  placed  in  the  flexed  position  on  a  double 
inclined  plane,  or  it  may  be  extended  by  means  of  any  of  the 
different  sorts  of  apparatus  already  described,  or,  finally,  it 
may  be  placed  in  a  long  fracture-box,  the  sides  of  which  are 
connected  by  hinges  with  the  bottom  piece,  and  extend,  on 
the  outer  side  to  the  axilla,  and  on  the  inner  to  the  pelvis, 
the  foot  being  secured  to  a  perpendicular  plane  attached  to 
the  lower  extremity  of  the  bottom-piece.  In  this  box,  the 
limb  may  repose  upon  a  bed  of  bran,  which  also  affords  the 
necessary  lateral  pressure  when  the  sides  of  the  box  are 
closed.  Probably,  if  the  fracture  be  seated  in  the  vicinity 
of  the  middle  of  the  bone,  it  can  be  treated  as  well  in  Phy- 
sick's  apparatus  as  in  any  other.  Either  of  the  splints  can 
be  bracketted  opposite  the  point  of  injury,  as  is  represented 


FRACTURES    OF    THE    OS    FEMORIS. 


189 


in  the  accompanying  drawing  from  Mr.  Erichsen's  Treatise, 
in  which  Mr.  Liston's  splint  is  thus  arranged.     (Fig.  77.) 


FIG.  77. 


The  bandage  of  Scultetus  is,  as  in  other  compound  frac- 
tures, the  best  compressing  bandage,  as  it  admits  of  removal 
and  adjustment  without  disturbing  the  limb.  The  wound 
itself  should  be  uncovered,  excepting  by  a  poultice,  or  some 
similar  dressing,  so  that  the  matter  may  have  free  escape, 
and  this  should  be  aided  by  moderate  pressure  upon  the  thigh, 
above  and  below  the  wound,  effected  by  the  bandage,  which 
should  be  made  to  act  with  particular  care  on  any  point  or 
points  beneath  which  the  matter  may  be  disposed  to  collect : 
if  an  abscess  should  form  at  any  point  remote  from  the  wound, 
as  happens  in  almost  every  compound  fracture,  it  should  be 
opened  by  the  knife. 

The  dressing  for  the  wound  must  be  varied  to  suit  its  ap- 
pearance at  different  times.  Great  cleanliness  of  the  parts, 
and  also  of  the  dressings,  should  be  observed. 

The  great  length  of  time  during  which  it  is  necessary  to 
confine  the  patient  to  bed  renders  it  advisable  to  resort  to 
every  expedient  to  prevent  sloughing ;  besides  the  frictions 
heretofore  recommended  in  compound  fractures,  the  position 
of  the  patient  should  be  changed,  from  time  to  time,  as  far  as 
may  be  consistent  with  the  security  of  the  limb  ;  the  use  of  the 
inclined  plane,  for  example,  may  be  alternated  with  that  of 
the  straight  splints. 

When  the  condition  of  the  wound  will  allow  of  more  direct 
compression  being  exercised  about  the  seat  of  fracture,  this 
means  should  be  instituted  as  an  aid  in  securing  a  proper  shape 
to  the  thigh.  For  this  purpose,  strips  of  adhesive  plaster,  or 
of  soap  plaster,  may  be  employed, — while  the  roller,  or  the 


190       FRACTURES  OF  THE  PATELLA. 

bandage  of  Scultetus,  cannot  be  used, — an  interval  being  left 
between  the  strips,  for  the  ready  escape  of  the  pus. 


SECTION  II. 

ON  THE  APPARATUS  AND  DRESSINGS  FOR  FRACTURES  OF  THE 

PATELLA. 

The  patella  may  be  broken  longitudinally,  or  transversely. 

1.  Longitudinal  fractures  of  this  bone  are  attended  with 
little  or  no  displacement  of  the  fragments,  as  a  general  rule ; 
hence  the  probability  of  perfect  reunion  by  bony  matter  is 
great,  and  the  treatment  is  very  simple.     The  leg  should  be 
extended  upon  the  thigh,  and  the  thigh  flexed  to  a  moderate 
degree  upon  the  pelvis,  while  a  roller  is  passed  around  the 
limb,  from  the  toes  to  the  upper  part  of  the  thigh,  being  made 
to  exercise  considerable  lateral  pressure  upon  the  fragments 
of  the  patella,  by  means  of  compresses  placed  at  each  side  of 
the  bone.     The  limb  should  be  laid  on  a  simple  inclined  plane, 
and,  for  the  sake  of  greater  security,  a  splint  should  be  bound 
to  its  under  surface.     The  application  of  these  retentive  means 
should  be  preceded,  if  there  be  much  inflammation  about  the 
joint,  by  leeching ;  and  after  the  bandage  is  applied,  cold  lo- 
tions may  be  employed,  if  required. 

2.  When  the  fracture  has  assumed  a  transverse  direction, 
a  considerable  degree  of  separation  of  the  fragments  is  una- 
voidable, the  retraction  of  the  upper  portion  varying  from  one 
to  three  or  four  inches,  according  to  the  power  of  the  exten- 
sor muscles  which  are  connected  with  the  base  of  the  patella, 
and  to  the  position  in  which  the  limb  has  remained  after  the 
injury. 

t  A  variety  of  mechanical  contrivances  have  been  resorted  to, 
to  remedy  the  effects  of  this  accident  and  to  maintain  the  frag- 
ments in  apposition.  The  bond  of  union  is  usually  ligamen-. 
tous,  so  commonly  that  Pibrac  offered  a  prize  of  one  hundred 
louis  d'or  to  any  one  who  would  show  him  a  specimen  of  trans- 
verse fracture  of  the  patella  cured  by  bony  union.  Specimens 
of  this  mode  of  healing  do,  however,  exist.  But  it  must  be 
borne  in  mind  by  the  surgeon  that,  although  a  very  good  ap- 


FRACTURES  OF  THE  PATELLA. 


191 


position  may  have  been  gained  and  retained  during  the  treat- 
ment, the  ligament  of  union  almost  invariably  becomes  elon- 
gated after  the  patient  commences  to  use  the  limb,  even  when 
a  splint  has  been  bandaged  to  its  under  surface  and  worn  thus 
for  a  long  time  after  confinement  to  bed  has  ceased.  This  fact 
should  always  be  impressed  upon  the  patient  and  his  friends, 
as  otherwise  the  surgeon  may  suffer  in  reputation. 

The  treatment  recommended  by  Sir  A.  Cooper  is,  that  the 
limb  be  lightly  bandaged  to  a  straight  splint  placed  all  along 
the  under  surface  of  the  limb,  the  knee  being  left  entirely  un- 
covered ;  that  the  extensor  muscles  of  the  leg  be  relaxed  by 
elevating  the  limb  upon  an  inclined  plane,  while  the  trunk  is 
flexed  upon  the  pelvis,  and  that  local  antiphlogistic  remedies 
be  applied  upon  the  joint,  until  inflammation  shall  have  ceased. 
Then  "  a  roller  is  applied  from  the  foot  to  the  knee,  to  pre- 
vent the  swelling  of  the  leg,  and  the  upper  portion  of  the  pa- 
tella is  pressed  downwards  towards  the  lower,  as  far  as  it  can 
be  without  violence,  so  as  to  produce  the  approximation  of  the 
fragments.  Rollers  are  applied  above  and  below  the  joint, 
confining  a  piece  of  broad  tape  next  the  skin  on  each  side, 
which  crosses  the  rollers  at  right  angles ;  these  tapes  are  next 
bent  down  and  tied  over  the  rollers,  so  as  to  bring  the  latter 
near  to  each  other,  and  thus  to  keep  down  the  upper  portion 
of  bone.  Sometimes,  instead  of  the  tape  on  each  side,  a  broad 
piece  of  linen  is  bent  over  the  rollers  on  the  fore  part  of  the 
joint,  and  is  there  confined,  so  as  to  approximate  the  portions 
of  bone  and  to  bind  down  the  upper  fragment  of  the  patella, 
that  its  lower  broken  edge  may  not  turn  forwards."  (Op.  cit. 
p.  205.)  (See  fig.  78.) 

FIG.  78. 


Another  method  recommended  by  the  same  high  authority 


192  FRACTURES    OF    THE    PATELLA. 

is  the  following : — A  leathern  strap  may  be  buckled  around 
the  lower  part  of  the  thigh,  above  the  broken  and  retracted 
fragment  of  bone  ;  from  this  circular  band  another  strap  should 
be  passed  along  the  side  of  the  leg  across  the  sole  of  the  foot, 
the  leg  being  extended  and  the  foot  flexed  as  much  as  possible. 
This  strap  is  then  carried  up  along  the  other  side  of  the  leg, 
and  buckled  to  that  which  has  been  fixed  around  the  thigh ; 
it  may  be  confined  to  the  foot  by  a  tape  tied  to  it,  and  to  the 
leg,  at  any  part,  in  the  same  manner.  This  is  a  very  conve- 
nient bandage  for  the  fractured  patella,  and  for  the  patella 
dislocated  upwards  by  the  laceration  of  its  ligament.  A  roller 
is  to  be  applied  around  the  leg.  (Op.  cit.  p.  205.)  (See  fig.  79.) 

FIG.  79. 


M.  Desault  directed  that  the  limb  should  be  held  in  the  po- 
sition above  advised,  by  an  assistant,  and  a  roller  passed 
around  the  leg  from  the  toes  to  the  knee,  confining  on  the 
front  of  the  leg  a  band  about  two  inches  wide  and  of  the 
length  of  the  limb ;  then  that  two  longitudinal  slits  be  made 
in  this  band,  opposite  the  patella,  through  which  the  surgeon 
passes  two  fingers  and  approximates  the  fragments :  that  a 
compress  be  applied  just  above  the  upper  fragment  and  re- 
tained there  by  several  turns  of  the  roller  passing  around  the 
knee  in  the  form  of  the  figure  8  ;  the  bandage  now  should  cover 
the  thigh,  a  padded  splint,  as  long  as  the  limb,  should  be  con- 
fined upon  its  under  surface,  and  the  whole  supported  on  an 
inclined  plane. 

M.  Gerdy  employs  an  invaginated  bandage,  such  as  is  used 
in  the  approximation  of  the  lips  of  transverse  wounds.  (See 
chap,  on  Wounds.)  The  leg,  as  high  as  the  knee,  is  enveloped 
by  a  roller,  which  also  confines  upon  the  front  of  the  leg  the 
tailed  portion  of  the  bandage,  the  slit  portion  being  secured 
upon  the  front  of  the  thigh  by  a  second  roller ;  then,  having 


FRACTURES  OF  THE  PATELLA. 


193 


placed  a  compress  above  the  upper  fragment,  and  another  be- 
low the  inferior,  pass  the  tails  of  the  bandage  through  the 
slits,  and  approximate  the  fragments  ;  this  having  been  effected, 
lay  the  portions  of  the  bandage  smoothly  along  the  limb,  and 
secure  them  by  turns  of  a  roller. 

Mr.  Amesbury  has  invented  an  apparatus  consisting  of 
two  wide  leathern  pads,  to  be  placed  one  on  the  anterior  face 
of  the  thigh  above  the  knee,  the  other  on  the  leg  below  the 
knee,  and  attached  to  each  other  by  straps  and  buckles.  In 
order  to  compress  the  extensor  muscles  of  the  leg,  and  at  the 
same  time  to  avoid  unnecessary  constriction  of  the  limb, 
these  pads  are  secured  by  means  of  straps  and  buckles,  to  a 
splint  placed  on  the  under  surface  of  the  member,  with  a 
foot-board  attached,  and  made  sufficiently  wide,  opposite  the 
knee,  to  project  a  little  beyond  it  upon  each  side.  The  upper 
pad,  and  with  it  the  corresponding  fragment  of  the  patella, 
is  made  to  approximate  the  lower  by  means  of  a  strap,  which 
passes  from  the  lower  edge  of  the  upper  pad,  along  the  side 
of  the  leg,  and  across  the  foot-board,  to  ascend  on  the  other 
side  of  the  leg  and  be  buckled  to  the  pad.  (Amesbury,  vol. 
ii.  p.  492,  &c.) 

Mr.  Lonsdale  has  contrived  an  instrument,  which  he  has 
found  very  efficacious  in  the  treatment  of  this  fracture.  It 
consists  of  a  splint  upon  which  the  limb  reposes,  and  to  which 
a  foot-piece  is  attached  in  such  a  way  as  to  be  movable  up 
and  down,  to  accommodate  the  splint  to  limbs  of  different 
lengths ;  to  the  under  surface  of  this  splint  two  vertical  iron 
bars  are  connected,  AB,  (see  fig.  80,)  at  about  its  centre, 
each  one  supporting  a  horizontal  arm  bent  at  right  angles, 
G  G ;  these  horizontal  pieces  slide  upon  the  upright  staffs,  but 

FIG.  80. 


194       FRACTURES  OF  THE  PATELLA. 

can  be  arrested  at  any  point  by  the  screws,  C  D  ;  from  these 
arms  depend  other  vertical  rods,  movable  upon  the  former, 
and,  like  them,  fixable  by  similar  screws,  E ;  finally,  to  the 
lower  end  of  each  of  these  second  perpendicular  rods,  an  iron 
plate,  F,  F,  of  a  horse-shoe  form',  is  attached,  by  means  of  a 
hinge-joint.  In  the  application  of  this  apparatus,  the  splint 
should  be  well  padded,  and  the  foot  and  leg  secured  to  it  by 
a  roller,  a  bandage  having  been  first  passed  around  these 
parts ;  then  the  surgeon  places  the  fragments  of  the  patella 
in  juxtaposition,  the  muscles  being  relaxed  as  before  directed, 
and  applies  the  upper  horse-shoe  plate  to  the  upper  part  of 
the  thigh,  a  soft  pad  intervening,  just  above  the  superior 
fragment,  —  not  touching  the  patella  itself,  while  the  other 
plate  is  applied  just  below  the  inferior  fragment ;  the  plates 
are  secured  in  these  relations  by  means  of  the  screws,  and  a 
roller  is  passed  around  the  thigh  and  the  upper  part  of  the 
splint.  The  limb  is  retained  during  the  treatment  in  the 
same  position  as  in  the  other  modes  already  described. 

Mr.  Lonsdale  states  the  advantages  of  this  apparatus  to  be, 
that  it  may  be  applied  immediately  after  the  fracture  occurs, 
that  it  produces  no  constriction  of  the  limb,  and  that  it 
leaves  the  injured  part  exposed  to  the  inspection  of  the  sur- 
geon during  the  whole  course  of  the  treatment,  and  allows  of 
the  application  of  antiphlogistic  remedies ;  he  has  found  it  to 
answer  the  purpose  for  which  it  was  intended,  in  a  very  satis- 
factory degree.  (Op.  cit.,  p.  427,  &c.) 

Mr.  Fergusson,describes  a  very  simple  and  neat  apparatus, 
contrived  by  Mr.  John  Wood,  for  the  treatment  of  this  injury. 
It  consists  of  a  splint  extending  from  the  pelvis  to  the  sole 
of  the  foot,  hollowed  to  receive  the  limb,  and  a  foot-piece 
attached ;  the  lower  extremity  of  the  splint  rests  upon  a 
block,  so  that  when  applied,  the  plane  upon  which  the  member 
reposes,  is  inclined.  The  limb  is  confined  upon  the  splint  by 
means  of  rollers,  the  fragments  of  the  patella  being  retained 
in  apposition  by  a  few  turns  after  the  manner  of  the  figure  8, 
and  to  prevent  these  latter  turns  of  the  roller  from  slipping, 
two  hooks  are  screwed  into  each  side  of  the  splint,  above  and 
below  the  position  of  the  knee,  around  which  the  bandage 
passes.  (Fig.  81.) 

The  apparatus  of  Boyer,  of  Dorsey,  Mogridge,  and  others, 


FRACTURES  OF  THE  PATELLA.       195 

FIG.  81. 


offer  no  particular  advantages  above  those  which  have  been 
described. 

M.  Malgaigne,  in  his  excellent  "  Trait£  des  Fractures,  p. 
764,  states,  that  he  has  seen  M.  Gama,  surgeon  to  the  mili- 
tary hospital  of  Val  de  Grace,  treat  successfully  cases  of 
transverse  fracture  of  the  patella,  by  means  of  strips  of  adhe- 
sive plaster  passed  above  and  below  the  fracture,  in  the  form 
of  the  figure  8,  the  limb  being  placed  upon  the  simple  in- 
clined plane.  And  in  the  Philadelphia  Medical  Examiner, 
p.  5,  Jan.,  1854,  Dr.  John  Neill  reports  two  cases  of  this 
injury  in  which  this  method  was  pursued.  It  is,  undoubtedly, 
the  simplest  and  the  best  plan  which  can  be  resorted  to. 

After  the  limb  has  been  thus  confined  for  six  or  eight 
weeks,  passive  motion  should  be  commenced  and  practised 
cautiously  but  diligently ;  in  the  course  of  two  weeks'  longer 
time,  the  patient  may  be  permitted  to  bear  moderately  upon 
the  foot  in  walking,  a  splint  being  bound  to  the  under  surface 
of  the  limb ;  he  should  step  on  the  sole  of  the  foot  flatly, 
and  not  on  the  toe ;  the  splint  should  be  worn  thus,  for  a  few 
weeks. 

3.  Rupture  of  the  tendon,   and  of  the  ligament  of  the 
patella  should  be  treated  in  the  same  manner  as  if  the  bone 
itself  were  broken. 

4.  Compound   fractures  of  the  patella  require  the  same 
general  principles  of  treatment  as  the  simple  forms.     But  in 
addition  to  the  injury  done  to  the  bone,  that  which  is  inflicted 
upon  the  soft  parts  and  on  the  joint  demands  attention,  and 
modifies  the  treatment.     The  indications   are,  to   close   the 
wound  immediately,  in  the  hope  that  it  will  heal  without  being 
accompanied  by  violent   constitutional   disturbance,  and   to 


196       FRACTURES  OF  THE  PATELLA. 

retain  the  fragments  of  the  patella  in  as  close  apposition  as 
the  condition  of  the  parts  will  permit.  The  limb  must  be 
placed  upon  a  splint  in  the  same  position  as  directed  for 
simple  fracture,  the  body  being  well  supported  in  the  flexed 
position  on  the  pelvis,  by  pillows  arranged  behind  the  back. 
The  lips  of  the  wound,  after  all  foreign  matter  has  been 
removed  from  the  opened  joint,  should  be  drawn  together  by 
strips  of  adhesive  plaster,  which  strips  may  be  so  applied  as 
to  draw  down  the  upper  fragment  of  the  patella,  and  to  retain 
it  in  apposition  with  the  lower :  then  a  piece  of  lint  should 
be  dipped  in  the  blood  which  flows  from  the  part,  or  in  some 
adhesive  and  glutinous  fluid,  and  laid  upon  the  wound,  where 
it  should  be  retained  by  a  light  bandage ;  all  pressure  being 
avoided  upon  the  joint  itself,  the  muscles  of  the  thigh  may 
be  moderately  compressed  by  a  roller,  the  same  which  con- 
fines the  splint  upon  the  limb.  Thus  arranged,  the  dressing 
should  not  be  disturbed  so  long  as  no  unpleasant  symptom 
arises ;  such  as  severe  inflammation,  free  suppuration,  &c. 
In  a  case  recorded  by  Sir  A.  Cooper  (op.  cit.,  p.  210,  11), 
the  first  applications  were  not  removed  until  a  month  after 
the  accident,  when  the  wound  was  found  nearly  healed  ;  ^the 
patient  in  this  case  recovered  with  a  perfectly  useful  limb. 

The  author  treated  in  this  manner,  at  the  hospital,  a  case 
of  compound  fracture  of  the  patella,  produced  by  a  kick  from 
a  horse,  in  which  a  similarly  happy  cure  followed.  If,  how- 
ever, violent  inflammation  follows  the  injury,  with  profuse 
discharge  and  much  constitutional  suffering,  the  primary 
dressing  must  be  at  once  removed,  and  antiphlogistic  reme- 
dies resorted  to,  —  as  local  and  general  depletion,  poultices, 
or  water-dressings,  &c.,  &c.  Passive  motion  should  be  cau- 
tiously instituted  as  soon  as  circumstances  will  admit  of  it. 
The  introduction  of  sutures  should  be  avoided  as  much  as 
possible ;  if  employed,  care  should  be  exercised  not  to  include 
the  ligament  in  the  suture.  (Sir  A.  Cooper,  op.  cit.,  case  137, 
p.  210.) 


FRACTURES  OF  THE  BONES  OF  THE  LEG.  197 

SECTION  III. 
FOR  FRACTURES  OF  THE  BONES  OF  THE  LEG. 

Like  those  of  the  fore-arm,  the  two  bones  of  the  leg  may 
be  broken  at  the  same  time;  or  each  may  be  fractured  sepa- 
rately. 

1.  When  both  the  tibia  and  fibula  are  broken,  the  maximum 
degree  of  displacement  is  produced,  partly  by  the  violence 
causing  the  fracture,  and  partly  by  the  action  of  the  powerful 
muscles  situated  about  the  leg.  The  line  of  fracture  is  gene- 
rally oblique,  in  almost  any  direction,  and  this  direction  influ- 
ences the  course  of  displacement  which  the  lower  fragment 
assumes.  When  the  solution  of  continuity  of  the  fibres  of  the 
bone  is  in  a  transverse  direction,  there  is  often  no  shortening 
of  the  leg,  but  merely  a  lateral  derangement ;  when,  however, 
the  fracture  is  oblique,  there  is  both  lateral  deformity  and 
shortening ;  in  the  former  injury,  the  fragments  are  easily 
retained  in  apposition,  after  reduction,  by  rest  alone ;  in  the 
latter,  a  continued  confining  apparatus  is  necessary  to  coun- 
teract the  disposition  on  the  part  of  the  muscles  to  contract 
and  to  draw  upwards  the  inferior  portion  of  the  bones.  Gene- 
rally, a  moderate  degree  of  mechanical  force,  with  the  limb 
in  the  straight  position,  suffices  for  the  successful  treatment 
of  simple  fractures  of  the  leg ;  there  are  instances,  however, 
in  which,  from  the  powerful  action  of  the  muscles  and  the 
direction  of  the  line  of  fracture,  such  deformity  is  produced 
that  it  becomes  desirable  to  take  advantage  of  the  effect  of 
position  to  aid  the  treatment,  as  in  fractures  of  the  thigh. 

The  simplest  plan  of  treatment  by  mechanical  means,  con- 
sists in  the  employment  of  the  "junks  ;" — these  are  generally 
made  of  pieces  of  wood,  or  of  bags  of  straw,  or  chaff,  rolled 
firmly  in  a  splint  cloth,  and  long  enough  to  extend  from  the 
lower  third  of  the  thigh  to  below  the  ankle,  on  each  side  of 
the  limb.  In  the  application  of  this  apparatus,  the  junks 
thus  rolled  are  glided  underneath  the  leg  upon  a  pillow,  which 
supports  the  whole  leg  and  the  heel ;  the  fracture  is  reduced, 
and  the  mechanical  supports  brought  in  contact  on  each  side 
with  the  knee  and  the  ankle,  all  the  intermediate  parts  of  the 
leg  being  likewise  apposed  to  the  lateral  supports,  either 
17* 


198  FRACTURES   OF    THE 

directly,  or  through  the  intervention  of  compresses  of  cotton, 
or  tow ;  the  whole  is  secured  thus  by  strips  of  muslin  passed 
around  the  junks. 

This  apparatus  leaves  the  anterior  face  of  the  leg  exposed 
to  the  examination  of  the  surgeon  and  to  the  action  of  local 
applications,  while  at  the  same  time  it  exerts  a  sufficiently 
powerful  lateral  compression  upon  the  leg,  to  retain  in  appo- 
sition the  fragments  of  the  bones,  in  all  cases  of  transverse 
fracture,  and  in  many,  or  most,  of  the  oblique.  It  does  not, 
however,  offer  so  great  a  degree  of  security  against  sudden, 
or  accidental,  movements  of  the  limb,  as  another  apparatus, 
which  is  almost  as  simple  as  itself, — the  fracture-box,  of  which 
mention  will  be  made  directly. 

Many  different  kinds  of  splints  have  been  contrived  at 
various  times,  and  by  different  surgeons,  for  the  treatment 
of  these  injuries.  The  best  have  all  sought  to  give  support 
to  the  inferior  surface  of  the  leg  and  the  foot,  and  also  to 
exert  more  or  less  lateral  compression.  Thus  the  splints  of 
Mr.  Neville,  highly  recommended  by  Mr.  Lonsdale  and  others, 
consist  of  a  light  iron  piece  padded,  for  the  inferior  face  of 
the  leg,  extending  from  the  lower  part  of  the  thigh  to  the 
foot,  at  which  point  it  curves  upwards,  to  form  a  support  for 
the  sole  of  the  latter, — and  of  two  lateral  splints,  of  the  same 
length  as  the  other,  and  also  padded,  and  secured  to  the  sides 
of  the  foot-piece  by  a  mortice-and-pinion  joint ;  circular  strips 
of  muslin  complete  the  apparatus. 

The  fracture-box,  however,  combines  all  the  advantages  of 
these  with  many  others  which  these  do  not  possess,  as  greater 
simplicity  of  construction,  and  in  consisting  of  but  a  single 
piece,  as  it  were,  by  which  greater  solidity  is  gained.  It  is 
composed  of  a  horizontal  plane  of  board  extending  from  a 
little  above  the  knee  to  the  sole  of  the  foot,  where  a  piece, 
rather  longer  than  the  foot,  and  of  the  same  width  as  the 
other  plane,  is  firmly  secured  to  it  at  right  angles :  side- 
pieces,  also  made  of  wood,  six  or  seven  inches  wide,  and  of 
the  same  length  as  the  bottom-piece,  are  connected  with  the 
latter  by  hinges.  (Fig.  82.)  To  apply  this  apparatus  to  the 
treatment  of  fractures  of  the  leg,  open  the  sides  of  the  box, 
and  place  a  pillow  upon  it,  soft  enough  to  adapt  itself  well  to 
the  inequalities  of  the  leg ;  then,  having  reduced  the  fracture, 
secure  the  foot  to  the  foot-board  by  a  strip  of  bandage,  and 


BONES    OF    THE    LEG. 


199 


FIG. 


close  the  sides  of  the  box,  more  or  less  tightly,  according  to 
the  condition  of  the  limb 
and  the  degree  of  pressure  FIG.  82. 

requisite  to  retain  the 
fragments  of  the  bones  in 
apposition;  the  sides  are 
thus  secured  by  strips  of 
muslin.  If  the  pillow  alone 
is  insufficient  to  exert  the 
requisite  pressure,  com- 
presses should  be  used  in 

addition,  and  these  should  be  so  placed  as  that  the  pressure 
may  bear  upon  those  particular  points  where  they  are  most 
needed.  Thus  the  proper  shape  of 
the  limb  may  be  easily  preserved, 
being  made  more  or  less  curved  by 
the  action  of  the  pillow  and  com- 
presses. In  this  manner,  some  of 
the  most  marked  deformities  may 
be  obviated.  Thus,  for  example,  in 
treating  the  fracture  of  which  the 
annexed  drawing  from  Fergusson's 
Practical  Surgery  (Am.  ed.,  p.  304) 
illustrates  the  appearance,  the  leg 
should  be  placed  in  the  fracture- 
box,  as  above  directed,  and  a  com- 
press be  applied  upon  the  tibial  side 
of  the  limb,  just  above  the  promi- 
nence of  bone,  while  another  is  laid 
on  the  fibular  side,  a  little  below  the  seat  of  fracture  ;  the 
compression  exercised  upon  these  points,  when  the  sides  of 
the  box  are  closed,  will  suffice  to  restore  the  leg  to  its  proper 
shape,  and  to  retain  the  fragments  in  complete  apposition. 
(Fig.  83.) 

The  shape  of  the  sound  leg  should  be  compared  daily  with 
that  of  the  broken  one,  and  any  deviation  from  the  proper 
line  in  the  latter  should  be  rectified  in  the  manner  pointed 
out.  The  foot  should  be  kept  upright  against  the  foot-board, 
the  heel  supported  by  the  pillow,  and  an  additional  pad,  if 
necessary.  If  there  be  any  signs  of  excoriation  or  sloughing 
on  the  heel,  or  malleoli,  pressure  should  be  immediately 


200  FRACTURES    OF    THE 

removed  from  these  points,  and  brought  to  bear  upon  others, 
and  the  surface  protected  by  simple  cerate,  or  stimulated  by 
frictions  with  spirits  of  camphor,  soap  liniment,  &c.,  &c.  Care 
is  requisite  lest  the  foot  fall  below  its  proper  line,  as  com- 
pared with  that  of  the  sound  leg  ;  to  obviate  this  liability  to 
displacement  of  the  lower  fragment,  a  pad  of  cotton  should 
be  placed  under  the  heel. 

The  advantages  of  the  fracture-box  are  evident :  it  is  per- 
fectly secure  ;  very  simple  in  its  construction  ;  fully  capable 
of  retaining  in  place  the  fragments  of  the  bones,  in  the  vast 
majority  of  fractures  of  the  leg,  and  it  leaves  the  limb  always 
open  to  inspection,  and  for  the  application  of  local  remedies. 
In  very  many  cases  of  this  fracture,  it  is  necessary  or  advisa- 
ble to  employ  sedative  lotions  ;  one  of  the  best  of  these  is  the 
solution  of  the  acetate  of  lead  ;  an  objection  to  this,  however, 
is  that  in  many  persons  it  irritates  the  skin  too  much,  and  in 
all  it  is  apt  to  leave  a  deposition  of  the  salt  upon  the  surface, 
which  is  sometimes  the  source  of  irritation.  When  any  liquid 
application  is  made,  or  any  other  dressing  which  may  soil  the 
pillow,  a  piece  of  soft  oil-cloth  should  be  spread  upon  the 
latter,  before  the  leg  is  placed  in  the  box. 

The  fracture-box  may  be  rendered  more  perfect  by  placing 
brackets  in  each  side,  through  which  pieces  of  iron-wire  shall 
be  passed,  arching  over  the  box  to  protect  the  limb  from  the 
pressure  of  the  bed-clothes. 

Very  often,  indeed,  in  fractures  of  the  leg,  the  skin  will 
be  found,  in  the  course  of  a  day  or  two  after  the  accident, 
covered  with  small  vesicles,  particularly  near  the  seat  of  the 
injury.  This  appearance,  in  persons  of  ordinarily  good  con- 
stitutions, is  a  matter  of  no  importance,  being  indicative  merely 
of  a  certain  degree  of  irritation  of  the  skin,  which  soon  sub- 
sides under  the  application  of  cold  water,  and  often  it  disap- 
pears if  no  local  means  are  used ;  but  the  same  appearance  in 
persons  of  bad  constitution,  especially  in  habitual  drunkards, 
is  frequently  the  precursor  of  erysipelas  or  mortification,  and 
should  be  carefully  watched. 

The  most  troublesome  simple  fracture  of  the  leg  is  that  in 
which  the  tibia  has  been  broken  obliquely,  the  line  of  frac- 
ture extending  downwards  and  forwards.  Here  the  powerful 
muscles  of  the  posterior  surface  of  the  leg  draw  the  inferior 
fragment  upwards,  leaving  the  sharp  extremity  of  the  upper 


BONES    OF    THE    LEG.  201 

part  of  the  bone  projecting  against  the  skin,  and  threatening 
to  produce  ulceration  of  the  integuments  at  this  point.  Where 
this  action  of  the  muscles  is  but  slight,  the  fracture-box  may- 
be employed,  care  being  had  that  the  inferior  fragment,  at 
the  seat  of  the  injury,  is  well  supported  by  a  compress  placed 
beneath  it.  In  other  instances  it  will  be  necessary  to  adopt 
some  plan  of  treatment  which  shall  oppose  the  muscular  con- 
traction by  direct  extension  and  counter-extension,  or  which 
shall  produce  the  same  effect  by  simply  relaxing  the  muscles 
in  question.  If  the  first  mode  be  resorted  to,  the  splints 
advised  by  Dr.  Hutchinson,  of  this  city,  may  be  employed. 
They  are  two  in  number,  extending  from  the  knee  to  some 
inches  beyond  the  foot ;  the  upper  end  of  each  splint  has 
perforations  made  in  it,  for  the  attachment  of  the  counter- 
extending  bands,  and  at  the  lower  extremity  of  each  is  a 
mortise,  through  which  a  bar  is  passed.  The  leg  is  laid  upon 
a  pillow,  upon  which  a  bandage  of  Scultetus  is  arranged; 
tapes  are  secured  upon  each  side  of  the  leg,  just  below  the 
knee,  by  means  of  a  roller,  and  a  gaiter,  or  a  cravat,  is  fast- 
ened to  the  foot  and  ankle ;  then  the  fracture  having  been  re- 
duced, the  leg  is  supported  by  an  assistant,  and  the  bandage 
of  Scultetus  folded  upon  it ;  the  splints  are  now  placed  by  the 
sides  of  the  leg,  pads  intervening,  the  counter-extending  bands 
are  fastened  to  the  upper  ends  of  the  splints,  and  the  extend- 
ing to  the  transverse  bar  passed  through  the  mortises  at  the 
lower  extremities,  and  the  whole  apparatus  thus  secured  by 
strips*  of  muslin  tied  around  it.  The  long  thigh  splints  of 
Desault  may  also  be  used  for  the  same  fracture,  instead  of  the 
shorter  splints  of  Hutchinson. 

Mr.  Fergusson  describes  an  apparatus  contrived  by  himself 
and  Mr.  Weiss,  which  is  intended  to  obviate  the  above  men- 
tioned deformities  resulting  from  muscular  contraction.  It 
consists  of  a  straight  bar  of  iron,  extending  from  the  knee 
beyond  the  sole  of  the  foot,  to  which  a  foot-piece  is  attached 
in  such  a  way  as  to  be  movable  upwards  towards  the  knee, 
and  also  laterally,  so  as  to  enable  the  surgeon  to  counteract 
any  tendency  to  inversion  or  eversion  of  the  foot ;  screws  are 
so  adjusted  as  to  secure  the  different  parts  of  the  apparatus 
in  any  desired  position.  The  lower  extremity  of  the  splint 
rests  upon  an  upright  arm,  which  reposes  steadily  upon  the 


202  FRACTURES    OF    THE 

bed  (fig.  84).     For  a  more  detailed  exposition  of  this  appara- 
tus, the  reader  is  referred  to  Mr.  Fergusson's  book,  p.  303. 


FIG.  84, 


Whichever  of  the  apparatuses  described  shall  be  employed, 
the  surgeon  may,  if  he  so  choose,  suspend  the  part, —  a  prac- 
tice supposed  by  many  to  be  attended  with  advantages.  At 
any  rate,  it  serves  very  well  to  vary  the  position,  and  may 
thus  add  to  the  comfort  of  the  patient.  To  accomplish  the 
suspension,  two  or  more  strong  iron  bars  may  be  made  to 
arch  over  the  limb,  and  the  apparatus  may  be  suspended 
from  them.  Or  the  more  elegant  arrangement  of  Mr.  Salter, 
recommended  and  described  by  Mr.  Fergusson,  (p.  305,)  may 
be  used.  It  is  "  in  most  respects  like  a  common  metal  cradle, 
but  at  the  top  will  be  seen  a  strong  and  smooth  bar  of  iron, 
on  which  a  couple  of  pulleys  play;  these  glide  readily ^long 
the  bar,  and  there  is  a  hook  attached  to  them  below,  to  which, 
by  means  of  a  chain,  a  case  for  holding  the  leg  is  attached. 
When  the  leg  is  placed  in  this  case,  it  will,  in  slight  move- 
ments of  the  body,  swing  from  the  hook  by  means  of  the 
chain;  and  in  larger  movements  —  as  in  using  the  bed-pan,  or 
taking  a  new  position  in  bed — the  pulleys  will  roll  to  and  fro, 
so  that  there  is  no  probability  of  the  fragments  gliding  upon 
each  other,  or  the  seat  of  fracture  being  in  any  way  disturbed. 
The  case  below  is  so  constructed  that  various  parts  of  it  can 
be  unhooked,  so  as  to  permit  of  dressings  being  applied  in 
instances  of  compound  fracture."  (Fig.  85.) 

If  the  treatment  by  position  is  decided  upon,  the  ordinary 
double  inclined  plane  may  be  used,  as  advised  in  fractures 
of  the  thigh,  a  foot-board  being  attached  to  the  lower  plane, 
so  that  the  foot  may  be  well  supported  in  the  proper  position. 


BONES    OF    THE    LEG 


203 


Or  the  fracture-box  just  described   may  be  placed  upon  a 
double  inclined  plane,  and  the  leg  properly  arranged  in  it. 


FIG.  85. 


The  last  will  probably  be  found  to  be  the  best  plan,  as  the 
leg  can  thus  be  more  securely  disposed  of,  than  when  the 
plane  alone  is  used ;  in  the  latter  case,  lateral  splints  should 
be  employed  to  steady  the  leg,  and  to  make  the  necessary 
compression  upon  the  sides.  By  thus  flexing  the  knee,  the 
muscles  which  draw  up  the  lower  fragment  of  the  tibia  are 
rendered  almost  inoperative,  and  the  apposition  of  the  two 
portions  of  bone  is  secured  very  readily ;  a  bandage  of  Scul- 
tetus  may  be  advantageously  employed  for  a  few  days,  around 
the  seat  of  fracture,  but  it  should  be  removed  daily,  and  the 
condition  of  the  leg  be  inspected. 

Mr.  Liston  has  devised  a  double  inclined  plane  for  the 
treatment  of  fractures  of  the  leg,  which  he  thinks  superior  to 
any  other ;  it  is  also  well  recommended  by  Fergusson  and 
many  other  English  surgeons.  "  It  consists  of  a  thigh  and 
leg-piece  of  sheet-iron,  and  a  foot-board  of  wood  ;  the  former 
are  joined  to  each  other  by  a  couple  of  hooks  and  a  screw, 
which  is  so  placed  that  the  two  plates  can  be  set  to  any  angle 
at  which  it  may  be  desirable  to  bend  the  knee,  and  the  foot- 
board is  so  affixed  that  it  may  be  slid  upwards  or  downwards. 


204  FRACTURES    OF    THE 

to  suit  the  length  of  the  limb,  and  fastened  by  a  side  screw 
in  any  position  that  may  be  advisable.  At  the  lower  end  of 
the  machine  there  is  a  cross-plate  of  iron,  which  is  so  attached 
that,  in  the  event  of  the  foot  being  raised  or  depressed,  it 
will  always  rest  flatwise  on  the  mattrass,  or  on  a  board 
placed  at  the  foot  of  the  bed  for  the  purpose  of  supporting 
it."  (Fig.  86.)  The  limb  is  to  be  laid  upon  the  splint, 
which  has  been  well  padded ;  cotton  or  tow  should  be  used  to 
adapt  the  surfaces  to  each  other,  and  to  aid  in  making  press- 
ure upon  particular  points,  and  a  roller  is  then  to  be  passed 
around  the  limb  and  the  splint.  The  angle  of  the  apparatus 
may  be  varied  as  may  be  judged  proper. 

FIG.  86. 


2.  If  the  tibia  alone  is  broken,  the  displacement  cannot  be 
very  great ;  the  accident  may  be  treated  by  any  of  the  methods 
above  spoken  of,  or  a  splint  of  pasteboard,  previously  moulded 
to  the  leg,  may  be  applied  upon  the  inner  or  inferior  surface, 
and  confined  by  a  roller,  or  by  the  starched  bandage,  and  the 
limb  kept  at  rest  upon  a  pillow.     But  even  in  simple  fracture 
of  the  tibia,  it  is  safer  to  make  use  of  the  fracture-box,  at  least 
during  the  first  week  or  ten  days :  the  same  precautions  and 
attentions  should  be  used  during  the  treatment,  as  in  the  cases 
above  considered,  though  they  are  less  necessary. 

3.  In  fracture  of  the  fibula  only,  when  the  injury  has  oc- 
curred above  the  lower  three  inches  of  the  bone,  nothing  more 
than  a  simple  lateral  or  angular  displacement  ensues,  and  the 
treatment  demanded  is  the  same  as  has  been  just  advised  for 
simple  fracture  of  the  tibia.     But  when  the  fracture  has  oc- 
curred at  the  lower  two  or  three  inches  of  the  bone,  consti- 
tuting what  is  called  "Pott's  fracture,"  a  great  lateral  dis- 
placement is  produced,  rendered  more  remarkable  by  rupture 
of  the  internal  lateral  ligament  of  the  ankle,  which  in  the  ma- 


BONES    OF    THE    LEG. 


205 


jority  of  cases  is  caused  simultaneously  with  the  fracture  of 
the  fibula.  The  annexed  drawing,  taken  from 
Mr.  Lonsdale's  book,  p.  522,  exhibits  the  point 
at  which  the  bone  is  usually  broken,  the  rup- 
ture of  the  internal  ligament,  and  the  peculiar 
deformity ;  (fig.  87,)  and  it  shows  the  applica- 
bility of  the  mode  of  treatment  recommended 
by  Dupuytren.  This  method  consists  in  the 
application  to  the  tibial  side  of  the  leg  of  a 
splint  and  cushion  of  peculiar  conformation. 
"  The  cushion,  made  of  cloth  and  filled  two- 
thirds  with  chaff,  should  be  two  feet  and  a  half 
long,  four  or  five  inches  wide,  and  three  or  four 
inches  thick.  The  splint,  from  eighteen  to 
twenty  inches  long,  two  and  a  half  inches  wide, 
and  three  or  four  lines  thick,  should  be  made 
of  firm  and  slightly  flexible  wood.  Lastly,  the 
two  bandages  used  should  be  each  four  or  five 
yards  in  length,  and  two  and  a  half  inches  wide. 
The  cushion,  folded  upon  itself  in  the  form  of  a 
wedge,  is  applied  to  the  inner  side  of  the  fractured  limb,  upon 
the  tibia,  its  base  directed  downwards,  being  laid  upon  the  in- 
ternal malleolus,  and  not  passing  below  it,  its  apex  reposing 
upon  the  internal  condyle  of  the -femur.  The  splint  laid  upon 
this  cushion  should  extend  beyond  it,  from  four  to  six  inches, 
and  beyond  the  inner  edge  of  the  foot  three  or  four  inches." 
One  of  the  rollers  is  used  to  confine  the  upper  part  of  the 
splint  and  cushion  upon  the  leg,  while  the  other  draws  the  foot 
towards  the  inferior  end  of  the  splint,  "  being  directed  succes- 
sively from  the  latter  over  the  upper  surface  of  the  foot,  upon 
its  outer  side,  under  the  sole  of  the  foot,  upon  the  splint ;  then 
from  this  upon  the  instep  and  under  the  heel,  to  return  again 
to  the  splint,  and  to  be  continued  in  the  same  manner  until  all 
the  bandage  is  used.  The  foot  is  brought  into  such  a  state  of 
adduction,  that  its  external  margin  becomes  inferior,  the  sole 
of  the  foot  being  directed  inwards,  and  its  internal  edge  up- 
wards." (Dupuytren,  Lemons  Orales,  torn.  i.  p.  226.)  The 
annexed  figure  illustrates  the  application  of  this  splint^ 
(Fig.  88.) 

Most  cases  of  this  fracture  may  be  treated  with  complete 
success  bv  the  fracture-box.     A  reference  to  fig.  87  will  show 
18 


206 


FRACTURES    OF    THE 


FIG.  88. 


the  points  upon  which  compresses  should  be  placed,  to  rectify 
the  deformity ;  viz.  one  upon  the  external  mal- 
leolus,  and  the  other  upon  the  side  of  the  tibia, 
just  above  the  extremity  of  the  bone;  then, 
when  the  sides  of  the  box  are  brought  up 
against  the  foot-board,  the  foot  will  be  forced 
into  its  proper  position,  and  thus  retained.  The 
advantages  of  Dupuytren's  splint  are,  that  the 
patient  need  not  be  confined  to  bed  for  any 
length  of  time,  but  may  walk  with  his  broken 
leg  supported  in  a  sling  depending  from  the 
neck,  or  he  may  be  allowed  to  travel,  if  his  cir- 
cumstances require  it,  provided  care  be  taken 
to  support  the  member. 

The  apparatus,  whichever  it  be  that  is  used 
in  the  treatment  of  fractures  of  the  leg,  may  be 
suspended  from  the  ceiling,  or  from  the  top  of 
the  bed,  according  to  the  plan  recommended 
by  Sauter  and  Mayor :  this  method  has  been 
already  sufficiently  explained,  to  enable  the  surgeon  to  adapt 
it  to  the  fractures  in  question.  It  is  difficult,  however,  to  see  the 
particular  advantages  which  would  result  from  such  a  modi- 
fication of  the  stationary  apparatus. 

When  fractures  of  the  leg  occur  in  persons  who  are  at  the 
same  time  affected  with  mania-a-potu,  perhaps  the  most  secure 
bandage  will  be  the  starch  bandage  with  splints  of  pasteboard. 
4.  Compound  fractures  of  the  leg  must  be  treated  after  the 
general  principles  recommended  in  similar  injuries  of  the  arm 
and  thigh.  The  bran-dressing,  first  resorted  to  by  Dr.  J.  K. 
Barton,  of  this  city,  and  to  which  allusion  has  been  before 
made  in  these  pages,  is  particularly  well  adapted  to  the  treat- 
ment of  compound  fractures  of  the  leg.  In  such  cases,  the 
bran  is  used  as  a  substitute  for  the  pillow  employed  in  simple 
fractures.  The  fracture-box  has  a  sufficient  quantity  of  the 
bran  laid  upon  the  bottom  of  it,  to  afford  a  soft  resting-place 
for  the  leg ;  the  leg  is  placed  upon  it,  the  form  of  the  limb  ad- 
justed as  well  as  possible,  the  foot  is  properly  attached  to  the 
foot-board ;  then  the  sides  of  the  box  are  closed,  and  the  box 
itself  filled  with  bran.  The  requisite  degree  of  lateral  pres- 
sure can  generally  be  gained  by  packing  the  bran  pretty  firmly 
opposite  particular  parts  of  the  leg ;  and  in  addition,  a  few 


BONES    OF    THE    LEG.  207 

strips  of  adhesive  plaster  may  be  drawn  around  the  limb  at 
the  point  of  fracture,  without  closing  the  wound  entirely,  or 
materially  interfering  with  the  ready  exit  of  the  pus.  Thus 
the  leg  is  imbedded  in  the  midst  of  a  substance  which  absorbs 
at  once  the  discharged  matters ;  which  diminishes  the  unplea- 
sant foetor,  by  secluding  the* pus  from  the  action  of  the  air; 
which  is  itself  clean,  light,  and  cool,  and  which  is  easily  re- 
newed. It  will  be  found,  moreover,  to  be  the  most  effectual 
mode  of  preventing  the  deposition  of  the  ova  of  flies  and  other 
insects  which,  in  our  warm  summers,  become  developed  in  the 
wound  and  are  the  source  of  great  inconvenience  and  annoy- 
ance. 

The  disposition  to  the  formation  of  abscesses  at  points 
remote  from  the  wound  is  often  met  with  in  compound  frac- 
tures of  the  leg.  When  formed,  they  should  be  opened  as 
soon  as  possible,  and  the  matter  confined  between  the  point 
of  incision  and  the  original  wound  by  a  few  strips  of  the 
bandage  of  Scultetus  laid  above  the  seat  of  abscess,  or  below 
it,  as  the  case  may  be. 

Very  generally  in  these  injuries,  the  wound  is  on  the  ante- 
rior face  of  the  leg ;  but  it  sometimes  happens  that  the  in- 
teguments are  ruptured  on  the  posterior  face,  or  on  one  side ; 
in  the  latter  cases  the  fracture-box  may  still  be  employed, 
care  being  had  that  too  great  pressure  is  not  exercised  upon 
the  wound  itself.  But  when  the  solution  of  continuity  exists 
on  the  posterior  part  of  the  leg,  some  apparatus  must  be  re- 
sorted to  which  will  allow  the  limb  to  repose  upon  its  side. 
For  this  purpose,  a  wooden  splint  may  be  used,  grooved  to 
receive  the  leg,  and  terminating  below  in  a  foot-piece.  The 
patient  should  repose  upon  his  side,  the  thigh  and  leg  flexed 
and  resting  upon  pillows.  The  broken  leg  should  be  placed 
in  the  splint,  (on  the  side  opposite  to  the  wound,  so  as  to 
leave  the  latter  exposed,)  and  confined  to  the  splint  at  the 
knee  and  at  the  foot,  by  means  of  rollers.  Little  force  will 
be  required,  generally,  to  retain  the  fragments  in  apposition, 
the  flexed  position  in  which  the  whole  limb  is  placed  itself 
relaxing  the  muscles :  but  compression  may  be  resorted  to,  if 
necessary,  by  strips  of  adhesive  plaster,  or  of  the  bandage 
of  Scultetus,  laid  above  and  below  the  wound,  while  this  is 
covered  with  a  poultice,  or  some  other  suitable  dressing ;  the 
pillows  should  be  protected  by  a  piece  of  oil-cloth,  upon 


208  FRACTURES    OF    THE 

which  bran,   cotton,   or   any   absorbing  material,  should  be 
placed,  to  catch  the  discharges  from  the  wound. 


SECTION  IV. 
FOR   FRACTURES    OF    THE    BONES    OF    THE    FOOT. 

Very  little  displacement  accompanies  simple  fractures  of 
the  bones  of  the  foot,  as  a  general  rule,  and  therefore  the 
treatment  is  very  simple.  The  foot  should  be  kept  at  rest, 
with  a  splint  of  wood,  or  of  pasteboarcf,  bound  to  its  sole, 
and  a  broad  compress  applied  on  the  superior  surface.  Or 
an  equally  good  plan  consists  in  placing  the  leg  in  a  fracture- 
box,  with  the  sole  of  the  foot  confined  to  the  foot-board,  by 
a  broad  band,  which  leaves  the  dorsum  of  the  foot  sufficiently 
exposed  to  the  action  of  local  antiphlogistic  applications. 

When  the  posterior  extremity  of  the  os  calcis  is  broken, 
there  need  not  be  much  displacement,  if,  as  is  generally  the 
case,  the  strong  plantar  ligaments  connected  with  this  part 
of  the  bone  remain  unruptured.  Under  other  circumstances, 
however,  the  fragment  is  more  or  less  drawn  from  its  natural 
position,  by  the  contraction  of  the  gastrocnemius  and  soleus 
muscles,  and  the  treatment  employed  must  be  adapted  to 
counteract  their  influence.  For  this  purpose  the  apparatus 
recommended  by  Mr.  Lonsdale  is  very  simple  and  effectual. 
It  consists  of  a  foot-piece  of  wood,  to  the  extremity  of  which 
the  end  of  a  slipper  is  attached,  for  the  reception  of  the  toes. 
The  foot-board  should  be  rather  shorter  than  the  sole,  so  as 
to  extend  from  the  toes  not  quite  to  the  heel ;  to  its  under 
surface  a  ring  is  attached.  A  pad,  or  compress,  is  placed 
upon  the  extremity  of  the  os  calcis,  (the  fragment  having 
been  restored  to  its  proper  position),  and  confined  thus  by  a 
few  turns  of  a  roller ;  then  a  strap  of  leather,  or  a  band  of 
webbing,  is  passed  through  the  ring  of  the  foot-board, 
upwards  over  the  heel  and  the  pad,  over  the  calf  of  the  leg 
to  the  lower  third  of  the  thigh,  where  it  is  reflected  upon 
itself,  —  the  knee  being  flexed,  and  the  foot  extended,  —  and 
confined  to  the  surface  by  turns  of  a  roller,  (fig.  89.) 

This  same  apparatus  will  answer  for  the  treatment  of  rup- 
ture of  the  tendo  Achillis,  with  the  addition  of  a  roller 


BONES  OF   THE    FOOT.  209 

Fia.  89.  FIG.  90. 


applied  carefully  from  the  toes  to  the  knee.  The  same  effect 
may  be  gained  by  a  method  even  more  simple  than  this,  as 
follows :  Encircle  the  lower  part  of  the  thigh  with  a  strap,  or 
a  roller  tightly  applied,  and  connect  this,  by  means  of  a 
strip  of  muslin,  to  the  heel  of  a  slipper  placed  upon  the  foot, 
— the  leg  being  flexed  upon  the  thigh ;  envelope  the  foot  and 
leg  in  a  roller.  The  annexed  drawing,  from  Druitt,  exhibits 
this  plan  of  treatment,  (fig.  90.) 

In  compound  fractures  of  the  bones,  the  foot  should  be 
kept  in  the  same  position  as  in  case  of  simple  fracture,  with 
a  poultice,  or  other  proper  dressing  applied  over  the  part. 


18* 


PAKT    IV. 

ON  THE.  MECHANICAL  MEANS  EMPLOYED  IN  THE  TREAT 
MENT  OF  DISLOCATIONS. 

A  DISLOCATION,  or  luxation,  is  defined  by  Sir  Astley 
Cooper  to  be,  "  a  displacement  of  the  articulating  portion  of 
a  bone  from  the  surface  on  which  it  \vas  naturally  received." 
This  faulty  position  is  maintained,  and  the  reduction  of  the 
dislocation  opposed,  by  a  combination  of  causes ;  sometimes, 
and  partially,  by  the  conformation  of  the  bony  surface  on 
which  the  displaced  member  rests,  as  the  prominent  margin 
of  the  acetabulum,  in  dislocations  of  the  hip ; — occasionally, 
to  a  certain  extent,  by  the  situation  and  condition  of  the  liga- 
ments about  the  joint ; — but  chiefly  and  in  every  case,  by  the 
powerful  clonic  and  tonic  action  of  the  muscles.  These  ob- 
stacles cannot  be  overcome  without  resort,  on  the  part  of  the 
surgeon,  to  physical  force. 

It  does  not  fall  within  the  province  of  this  volume  to  dis- 
cuss the  pathology  of  this  class  of  accidents ;  its  limits  and 
its  legitimate  intention  permit  only  a  description  of  the  me- 
chanical means  employed  in  their  treatment.  The  subject 
naturally  divides  itself  into  two  branches :  1st,  the  means  of 
reducing  the  dislocation,  or  of  restoring  the  displaced  bone  to 
its  natural  situation ;  2d,  the  mode  of  retaining  the  bone  in 
place,  until  the  necessary  reparation  of  the  injury  done  to 
the  tissues  shall  have  become  perfected. 

Luxations  are  replaced  by  means  of  muscular  force  acting 
directly  upon  the  two  bones  involved,  or  indirectly  through 
the  intervention  of  some  mechanical  apparatus,  the  object  of 
which  is  to  increase  the  power  of  the  muscles,  and  to  render 
it  more  uniform  and  more  equable  in  its  operation.  The  force 
thus  excited  must  act  in  two  opposite  directions  :  one,  —  the 
extending, — upon  the  movable  part,  that  which  has  been  dis- 
placed ;  while  the  counter-extension  is  exercised  on  the  oppo- 
site part,  serving  merely  to  fix  and  steady  it.  The  points 


DISLOCATIONS.  211 

upon  which  these  forces  operate  vary  in  different  dislocations  : 
generally,  the  muscles  which  directly  surround  the  joint,  and 
which,  if  they  are  excited  to  contraction  by  any  cause, 
may  interfere  with  the  execution  of  the  object  in  view,  should 
not  be  compressed  by  the  extending  and  counter-extending 
powers,  unless  from  motives  of  convenience  and  expediency. 

To  assist  the  action  of  "the  mechanical  means,  in  all  in- 
stances where  the  resistance  of  the  muscles  is  great,  or  where 
much  pain  is  likely  to  be  experienced  for  any  length  of  time, 
it  is  important  to  depress  the  irritability  and  power  of  the 
muscles,  and  the  nervous  sensibility,  by  anaesthetics,  or  some 
other  agent. 

When  the  dislocation  has  been  reduced,  there  is,  generally, 
but  little  disposition  to  re-displacement :  it  is  necessary  merely 
to  keep  the  muscles  surrounding  the  joint,  and  the  joint  itself, 
in  a  state  of  repose,  for  a  certain  time.  This  object  is  secured 
by  the  application  of  retentive  bandages  and  splints. 

The  special  dislocations  will  be  briefly  considered,  with 
particular  reference  to  the  mode  in  which  the  various  me- 
chanical means  alluded  to  are  applied. 


CHAPTER  I. 

DISLOCATIONS  OF  THE   BONES  OF  THE  HEAD  AND  TRUNK. 

SECTION  I. 
DISLOCATION  OF  THE  LOWER  JAW. 


FIG.  91. 


REDUCTION. — In  this  accident  the  articular  surface  of  one, 
or  of  both,  of  the  condjloid  processes  of  the  inferior  maxilla 
rests  upon  the  base  of  the  zygomatic  process,  being  thrown 

forwards  out  of  the 
glenoid  cavity,  as  is 
represented  in  the  an- 
nexed wood  cut,  (fig. 
91.)  To  remedy  the 
deformity,  the  surgeon 
places  his  thumbs,  well 
wrapped  around  with 
muslin,  to  protect  them 
from  injury,  between 
the  posterior  molar 
teeth  on  each  side  of 
the  jaw,  grasping  the 
base  of  the  bone  on 
each  side  with  his  fin- 
gers ;  then,  the  patient's  head  being  well  supported  against 
the  back  of  a  chair,  or  by  the  hands  of  an  assistant,  the  sur- 
geon presses  his  thumbs  strongly  downwards  upon  the  molar 
teeth,  while  with  his  fingers  he  forces  the  chin  upwards ;  thus 
the  condyloid  processes  are  removed  from  their  false  position, 
and  by  the  contraction  of  the  muscles  connected  with  the 
posterior  part  of  the  bone,  are  drawn  into  the  glenoid 
cavities. 

The  succeeding  treatment  consists  in  the  application  of  a 
simple  retentive  bandage,  as  that  of  Barton,  or  of  Gibson, 

(212) 


DISLOCATIONS  OF  THE  CLAVICLE.     213 

(see  Fractures  of  Lower  Jaw,)  and  in  nourishing  the  patient 
for  the  following  two  or  three  weeks  with  liquid  food. 


SECTION  II. 
DISLOCATIONS   OP  THE   BONES   OF  THE  TRUNK. 

If  the  vertebrae,  the  ribs,  or  the  bones  of  the  pelvis  chance 
to  be  separated  from  their  articular  connexions,  the  accident 
is  generally  accompanied  by  other  serious,  if  not  fatal,  in- 
juries to  the  organs  contained  in  the  thoracic,  abdominal  and 
pelvic  cavities.  The  surgeon  can  do  little  or  nothing  towards 
replacing  the  dislocated  bones.  Perfect  rest  should  be  en- 
joined, with  the  use  of  such  local  and  general  antiphlogistic 
remedies  as  may  be  requisite.  The  simple  body-bandage  for 
the  chest,  or  pelvis,  will  effect  all  that  can  be  expected  of 
any  mechanical  contrivance ;  or  the  bandages  shown  in  figures 
29,  31  and  76  may  be  employed,  according  to  the  region 
injured. 

SECTION  III. 
,    DISLOCATIONS    OF    THE    CLAVICLE. 

Either  articular  extremity  of  the  clavicle  may  be  luxated : 
the  modes  of  effecting  reduction  are  very  similar  in  all  varie- 
ties of  the  accident.  The  patient  being  seated,  the  surgeon 
takes  a  position  behind  him,  grasping  each  shoulder,  and 
having  one  knee  placed  against  the  spine  between  the  shoul- 
ders, so  as  to  steady  the  patient,  while  he  draws  the  shoulders 
backwards,  and  thus  operates  upon  the  clavicle.  The  natu- 
ral distance  between  the  shoulders  having  been  regained, 
pressure  must  be  made  upon  the  extremity  of  the  reduced 
bone  with  the  hand,  until  a  suitable  bandage  can  be  applied. 

AFTER-TREATMENT.  —  The  retentive  means  employed  to 
maintain  the  reduction  should  accomplish  two  indications ; 
viz.,  to  prevent  the  shoulder  from  falling  downwards,  for- 
wards, and  inwards,  and  to  exert  a  certain  degree  of  pressure 


214 


DISLOCATIONS  OF  THE  CLAVICLE. 


FIG.  92. 


upon  the  dislocated  extremity  of  the  clavicle.    If  the  humeral 
end  of  the  bone  has  been  luxated,  both  of  these  indications 

will  be  fulfilled  by  the  appli- 
cation of  the  figure-8  ban- 
dage of  both  shoulders,  a  pad 
being  placed  in  the  axilla  of 
the  affected  side  and  a  com- 

Sress  upon  the  end  of  the  bone 
5g.  92),  while  the  fore-arm 
is  supported  in  a  sling  upon 
the  front  of  the  chest.  If 
the  accident  has  occurred  to 
the  sternal  extremity  of  the 
clavicle,  the  same  bandage 
should  be  employed,  with  the 
addition  of  a  compress  upon 
the  injured  articulation,  to 
be  retained  in  this  situation 
by  means  of  a  few  turns  of  a 
roller  made  to  encircle  ob- 
liquely the  upper  part  of  the  chest,  passing  across  the  root 
of  the  neck  of  the  injured  side,  over  the  sternal  extremity  of 
the  clavicle,  under  the  axilla  of  the  sound  side,  and  so  around 
the  back  to  the  starting-point.  Dr.  W.  Poyntell  Johnston, 
some  years  ago  lecturer  on  Surgery  in  this  city,  was  in  the 
habit  of  recommending  the  use  of  the  common  hernia-truss  in 
the  treatment  of  this  accident,  the  pad  being  made  to  press 
upon  that  extremity  of  the  clavicle  which  had  been  dislocated ; 
the  truss  can  be  easily  secured  in  position  by  a  few  turns  of 
a  roller,  or  by  a  handkerchief. 


CHAPTER  II. 

DISLOCATIONS    OF  THE    BONES    OF  THE    UPPEE 
EXTREMITY. 

SECTION    I. 
DISLOCATIONS    OF    THE    HUMERUS. 

THE  head  of  the  humerus  is  liable  to  three  principal  varie- 
ties of  displacement,  viz.,  1st,  in  the  direction  downwards  into 
the  axilla ;  2d,  forwards,  under  the  pectoralis  major  muscle ; 
3d,  on  the  dorsum  of  the  scapula. 

In  all  of  these,  the  principle  of  reduction  is  the  same,  vary- 
ing only  in  the  line  in  which  the  reducing  force  is  made  to 
operate.  There  are,  however,  several  methods  by  which  the 
restoration  may  be  accomplished. 

1.  By  the  heel  in  the  axilla.  The  patient  should  assume 
the  recumbent  position  on  a  bed,  or  on  the  floor;  the  surgeon 
sits  by  his  side,  and  places  one  heel  in  the  axilla,  in  contact 
with  the  head  of  the  humerus,  thus  fixing  the  body ;  the 
extending  force  is  applied  either  to  the  arm  above  the  elbow, 
or  to  the  wrist.  By  the  former  plan,  the  surgeon  flexes  the 
patient's  fore-arm  so  as  to  relax  the  biceps  muscle,  and  secures 
a  double  roller-towel  upon  the  arm  above  the  elbow,  by  means 
of  a  wetted  bandage  ;  he  then  passes  the  towel  over  his  own 
neck,  and  under  the  axilla  of  the  side  next  the  patient. 
(Fig,  93.)  It  may  be  objected  to  this  method,  that  the 
triceps  and  biceps  muscles  may  be  stimulated  to  contraction 
by  the  pressure  exercised  upon  them,  and  thus  oppose  the 
reduction.  By  the  other  mode,  the  surgeon  grasps  the  pa- 
tient's wrist  either  with  the  hand,  or  through  the  medium  of 
a  bandage,  or  of  a  double  towel  arranged  in  the  manner  above 
described.  The  last  method  is  probably  the  best,  as  it  does 
not  directly  afiect  the  muscles  which  pass  from  the  scapula  to 
the  lower  part  of  the  humerus  and  the  fore-arm.  By  employ- 
ing the  double  towel,  in  either  mode  of  operating,  the  surgeon 
may  avail  himself  of  the  power  of  the  muscles  of  the  back, 

(215) 


216  DISLOCATIONS    OF    THE    HUMERUS. 

as  well  as  of  those  of  the  arms.     The  extension  should  be 
made  gradually  and  steadily  in  the  direction  assumed  by  the 


FIG.  93. 


humerus,  and  the  head  of  the  bone  may  be  acted  upon  by  the 
heel  of  the  surgeon  also,  so  as  to  be  dislodged  from  its  position 
in  the  axilla. 

2.  By  relaxing  the  supra-spinatus  muscle  and  the  deltoid, 
which,   according  to   Sir  A.  Cooper  (op.  cit.  pp.  321,  2),  are 


FIG.  94. 


the  chief  opponents  of  the  reduction.     The  patient  lies  down, 
as  in  the  first  method ;    the  surgeon  sits  behind  him,  and 


DISLOCATIONS    OF    THE    HUMEKUS* 


217 


extends  the  dislocated  arm  with  one  hand,  while  with  the 
other  he  fixes  the  scapula.  (Fig.  94.)  If  this  simple  manual 
force  is  not  sufficient,  the  scapula  may  be  secured  by  means 
of  a  double  towel  passed  around  it,  crossing  the  axilla,  and 
confined  to  the  bedstead,  or  to  the  floor,  on  the  opposite  side 
of  the  patient ;  while  pulleys  are  employed  to  make  the  ne- 
cessary extension,  as  will  be  explained  directly;  or,  again, 
extension  may  be  effected  by  means  of  the  double  towel 
passed  around  the  surgeon's  back  and  shoulder,  as  already 
described. 

3.  By  the  pulleys.  It  is  necessary,  in  the  employment  of 
the  pulleys,  to  fix  the  scapula  by  some  mechanical  means. 
This  may  be  best  accomplished  by  a  broad  piece  of  canvass, 
or  leather,  in  which  a  hole  is  made  large  enough  to  admit  the 
shoulder ;  this  band  should  pass  in  front  of  and  behind  the 
chest,  and  be  secured  to  a  hook  in  the  wall,  or  the  floor,  if  the 
patient  is  in  the  recumbent  position.  The  annexed  drawings 
from  Fergusson,  illustrate  the  kind  of  pulleys  which  are  used, 

FIG.  95. 


and  the  ring  to  which  one  of  their  hooks  is  attached  during 
the  extension.  (Fig.  95.)  The  other  hook  should  be  fas- 
tened to  a  towel,  which  has  been  secured  upon  the  arm  above 
the  elbow,  by  means  of  a  wetted  roller.  The  cord  of  the 
pulleys  should  be  drawn,  by  an  assistant,  slowly  and  steadily, 
and  be  relaxed  as  soon  as  the  surgeon,  who  has  his  hands 
upon  the  head  of  the  bone  and  the  shoulder,  feels  that  the 
former  has  been  drawn  out  from  beneath  the  glenoid  cavity. 

-Li/ 


218  DISLOCATIONS    OF    THE    HUMERUS. 

It  may  be  of  service  sometimes,  that  the  surgeon  should  place 
his  knee  beneath  the  humerus  near  to  its  head,  in  order  to 
gain  a  fulcrum  upon  which,  by  depressing  the  elbow,  the 
head  of  the  bone  may  be  elevated  towards  the  glenoid  cavity. 
(Fig.  96.) 

FIG.  96. 


The  use  of  the  pulleys  is  necessary  in  cases  where,  from 
long-standing  dislocations,  or  from  the  great  muscular  powers 
of  the  individual,  a  very  considerable,  and  a  very  steady  and 
long-sustained  force  is  required  to  reduce  the  head  of  the 
bone.  In  such  instances,  resort  should  be  had  to  general  de- 
pressing means,  as  bleeding,  the  administration  of  nauseating 
doses  of  tartar  emetic,  &c. 

Any  of  the  varieties  of  dislocation  of  the  humerus  may  be  re- 
duced by  these  means,  but  the  direction  in  which  the  extending 
force  should  act,  must  be  modified  with  each  luxation.  In 
the  dislocation  downwards,  the  arm  should  be  drawn  down- 
wards and  a  little  outwards  from  the  side,  to  correspond  with 
the  direction  of  the  axis  of  the  humerus.  In  the  luxation 
forwards,  the  arm  points  outwards  and  backwards,  and  the 
reducing  force  should  operate  in  the  same  direction.  When 


DISLOCATIONS    OF   THE    HUMEEUS.  219 

the  head  of  the  bone  is  thrown  upon  the  dorsum  of  the  scapula, 
the  extension  must  be  made  forwards  and  outwards. 

A  complicated  and  expensive,  though  ingenious  apparatus, 
known  in  this  country  and  in  Europe  as  "  Jarviss  Adjuster" 
was  invented  some  years  ago  by  Dr.  G.  0.  Jarvis,  of  Connec- 
ticut. It  consists  of  several  pieces  of  iron,  shaped  to  corre- 
spond with  the  form  of  the  different  parts  of  the  upper  and 
lower  extremities  ;  these  are  to  be  secured  upon  the  dislocated 
member  by  means  of  straps  and  buckles.  The  extending 
power,  which  accomplishes  the  reduction,  is  applied  by  means 
of  a  rack-and-pinion-wheel.  It  is  applicable  both  to  disloca- 
tions and  to^  fractures.  Those  who  are  desirous  of  seeing 
representations  of  the  apparatus,  and  the  manner  in  which  it 
is  to  be  employed,  we  would  refer  to  a  series  of  lectures  upon 
the  subject  by  its  inventor,  published  in  the  London  Lancet, 
for  1846,  Vol.  I. 

The  apparatus  is  a  very  powerful  one,  unquestionably,  and, 
we  dare  say,  can  be  made  to  accomplish  what  its  maker 
promises.  But  we  believe,  that  with  the  ordinary  pulleys, 
aided  by  anaesthetic  influence,  the  surgeon  can  exert  as  much 
force  as  is  necessary  or  safe,  and  can  direct  it  perhaps  better 
than  by  the  "Adjuster."  Moreover,  (and  this  we  think  a 
very  important  consideration  !)  the  surgeon  knows  how  much 
force  he  employs,  if  he  uses  the  pulleys;  whereas,  if  he 
brings  the  apparatus  in  question  to  bear  upon  a  dislocation  or 
fracture,  he  cannot  judge  of  this  so  accurately,  and  he  is 
consequently  much  more  likely  to  do  mischief  in  his  efforts 
to  benefit  his  patient.  These  considerations,  together  with 
the  costliness  and  complicated  character  of  the  machine,  and 
the  fact  that  we  can  succeed  very  well  with  the  means  which 
have  been  so  long  in  use,  render  it  hardly  worth  while  to 
burthen  ourselves  with  "Jarvis's  Adjuster." 

AFTER-TREATMENT. — The  fore-arm  should  be  supported  in 
a  sling,  in  the  semi-flexed  position,  on  the  chest,  a  pad  should 
be  secured  in  the  axilla,  and  the  arm  bound,  with  a  moderate 
degree  of  pressure,  to  the  side.  Local  antiphlogistic  applica- 
tions, as  lead-water,  cold  poultices,  or  leeches,  may  be  made 
as  required.  The  apparatus  should  be  continued  for  ten  days 
or  two  weeks. 


220      DISLOCATIONS    AT    THE    ELBOW-JOINT. 

SECTION  II. 
DISLOCATIONS    AT    THE    ELBOW-JOINT. 

Of  these  there  are  six  varieties :  1st,  in  which  both  bones 
are  thrown  backwards,  the  olecranon  process  projecting  very 
much  posteriorly ;  2d,  in  which  both  bones  are  drawn  back- 
wards and  inwards ;  3d,  when  both  are  thrown  backwards  and 
outwards ;  4th,  the  ulna  alone  is  forced  backwards,  the 
orbicular  ligament  of  the  radius  being  ruptured,  but  this  bone 
itself  remaining  on  the  anterior  face  of  the  external  condyle ; 
5th,,  the  radius  forced  forwards  into  the  depression  above  the 
external  condyle,  the  ulna  remaining  in  situ ;  6th,  the  radius 
thrown  backwards  behind  the  external  condyle  of  the  humerus. 
In  all  the  varieties  the  reduction  is  generally  easily  effected. 
In  the  first  four  species,  the  restoration  may  be  accomplished 
by  placing  the  knee  at  the  bend  of  the  elbow,  and  flexing  the 
fore-arm  upon  it,  the  lower  part  of  the  upper  arm  and  the 
fore-arm  being  grasped  by  the  hands  of  the  surgeon.  The 
dislocations  of  the  radius  may  be  remedied  by  fixing  the 
humerus  and  making  extension  from  the  hand,  while  the  bone 
is  thrown  forwards ;  if  the  luxation  be  backwards,  the  same 
extension  and  counter-extension  should  be  made,  while  at  the 
same  time  the  fore-arm  should  be  flexed,  thus  forcing  the 
biceps  to  draw  the  radius  to  its  proper  place. 

SUBSEQUENT  TREATMENT. — The  fore-arm  should  be  placed 
in  the  semi-flexed  position,  and  an  angular  splint  should  be 
bandaged  upon  the  front  of  the  whole  limb,  compresses  being 
placed  upon  the  head  of  the  bones  opposite  the  direction  of 
the  luxation.  This  confinement  must  be  maintained  for  two 
or  three  weeks,  passive  motion  being  carefully  instituted  after 
the  first  few  days. 


DISLOCATIONS    OF    THE    FORE-ARM.          221 

SECTION  III. 
DISLOCATIONS  OF   THE   LOWER  EXTREMITY  OF  THE  FORE-ARM. 

These  accidents  are  usually  caused  by  falls  upon  the  hand. 
Both  the  radius  and  ulna  may  be  thrown  either  backwards  or 
forwards  upon  the  wrist,  causing  considerable  projection  in 
these  situations,  or  .one  of  the  bones  only  of  the  fore-arm  may 
be  separated  from  its  connexions  and  displaced  anteriorly,  pos- 
teriorly, or  laterally.  The  reduction  is  easily  accomplished 
by  simply  extending  and  counter-extending  from  the  hand  and 
the  fore-arm,  and  making  moderate  lateral  pressure  at  the 
same  time,  if  the  displacement  be  at  the  side  of  the  wrist. 

SUBSEQUENT  TREATMENT. — Place  a  straight  splint  on  the 
front,  and  another  on  the  back  of  the  fore-arm  and  hand,  with 
compresses  on  the  anterior  and  posterior  surfaces  of  the  wrist, 
and  secure  the  whole  by  a  roller.  The  fore-arm  should  be 
supported  in  a  sling. 


SECTION  IV. 
DISLOCATIONS   OF  THE   BONES   OF  THE  HAND. 

Instances  have  been  met  with,  in  which  some  one  or  more 
of  the  carpal  bones  have  been  thrown  from  their  natural  posi- 
tions, so  as  to  form  projections  upon  the  back  of  the  hand, 
without  a  wound  of  the  integuments.  They  may  generally  be 
replaced  by  pressure :  the  reduction  should  be  maintained,  by 
placing  compresses  upon  the  palmar  and  dorsal  aspects  of  the 
wrist,  and  upon  these  straight  splints,  the  whole  to  be  enve- 
loped in  the  folds  of  a  roller.  The  hand  should  be  supported 
in  a  sling. 

The  same  treatment,  conjoined  with  some  degree  of  exten- 
sion in  the  reduction,  is  applicable  to  dislocations  of  the  meta- 
carpal  bones,  should  they  occur  without  laceration  of  the  in- 
teguments. 
19* 


222 


DISLOCATIONS    OP    THE    HAND. 


Dislocations  of  the  phalanges  may  ordinarily  he  reduced 
•without  much  difficulty,  if  the  accident  is  attended  to  soon 
after  its  occurrence.  Sometimes  restoration  may  he  accom- 
plished by  simply  bending  the  displaced  phalanx  over  the  head 
of  the  bone  from  which  it  has  been  dislocated,  as  represented 
in  the  annexed  drawing.  (Fig.  97.)  Frequently,  however,  con- 

FIG.  97. 


siderable  extension  and  counter-extension  are  requisite.  To 
effect  this,  a  piece  of  cord  should  be  wound  around  the  pha- 
lanx, the  skin  being  protected  by  a  covering  of  wetted  buck- 
skin ;  then,  the  hand  being  fixed,  the  surgeon  should  extend 
the  finger,  at  first  in  the  axis  of  the  bone,  and  gradually  flex 
it  towards  the  palm,  in  order  to  relax  the  flexor  muscles,  if 
the  dislocation  be  posteriorly;  or,  if  the  phalanx  has  been 
thrown  upon  the  palmar  face  of  the  other  bone,  it  should  be 
forced  a  little  backwards,  during  the  extension.  (Fig.  98.) 

Fia.  98. 


The  most  convenient  mode  of  securing  the  extending  cord 
or  tape,  is  by  making  what  is  termed  the  "clove-hitch,"  as 
shown  in  the  accompanying  drawing,  (fig.  99,)  from  Fer- 
gusson. 


DISLOCATIONS    OF    THE    HAND. 


223 


FIG.  99. 


Dislocation  of  the  phalanges  of  the  thumb  is  most  difficult  of 
reduction.  The  following  is  the 
method  recommended  by  Sir  A. 
Cooper,  p.  446 :  "  The  extension 
is  to  be  made  by  bending  the 
thumb  towards  the.  palm  of  .the 
hand,  to  relax  the  flexor  muscles 
as  much  as  possible,  and  the  fol- 
lowing is  the  mode  of  applying 
the  extending  force :  The  hand 
is  to  be  first  steeped  in  warm 
water  for  a  considerable  time,  to 
relax  the  parts  as  much  as  pos- 
sible ;  then  a  piece  of  thin  wetted 
leather  is  to  be  put  around  the 

phalanx,  and  as  closely  adapted  to  the  thumb  as  possible :  a 
piece  of  tape  about  two  yards  in  length  is  next  to  be  applied 
upon  the  surface  of  the  leather,  in  the  knot  called  the  "  clove- 
hitch,"  for  this  becomes  tighter  as  the  extension  proceeds. 
An  assistant  places  his  middle  and  forefinger  between  the 
thumb  and  forefinger  of  .the  patient,  and  makes  the  counter- 
extension,  whilst  the  surgeon,  assisted  by  others,  draws  the 
phalanx  from  the  metacarpal  bone,  directing  it  a  little  inward 
towards  the  palm  of  the  hand."  (Fig.  100.) 

FIG.  100. 


The  quiescence  of  the  joint  after  dislocation  of  the  metacar- 
pal, or  phalangeal  bones,  is  to  be  maintained  by  splints  and 
compresses  placed  upon  the  dorsal  and  palmar  aspects  of  the 
hand. 


CHAPTER  III. 

DISLOCATIONS   OF  THE  BONES   OF  THE  LOWER  EXTREMITY. 

SECTION  I. 
DISLOCATIONS    OF    THE    HIP-JOINT. 

OF  these  there  are  four  chief  varieties,  named  from  the 
false  position  which  the  head  of  the  os  femoris  assumes ;  they 
are  as  follows :  —  1st,  upwards,  or  on  the  dorsum  ilii ;  2d, 
downwards,  or  into  the  foramen  ovale;  3d,  backwards  and 
upwards,  or  into  the  ischiatic  notch ;  4th,  forwards  and  up- 
wards, or  on  the  body  of  the  pubis. 

These  require,  on  the  part  of  the  surgeon,  the  employment 
of  a  greater  degree  of  force  in  reduction  than  dislocations  of 
any  other  bone,  owing  to  the  much  greater  power  of  the 
muscles  concerned.  In  young  children  they  may  generally 
be  restored  by  simple  manual  extension  and  counter-extension, 
as  the  luxations  of  the  humerus ;  but  in  adults,  the  pulleys 
should  always  be  employed,  and  it  is  almost  always  advisable 
to  have  recourse  also  to  depressing  agencies,  as  bleeding  to 
the  amount  of  from  twelve  to  twenty  ounces,  or  the  hot-bath 
at  100°,  or  the  administration  of  tartar  emetic  in  doses  of 
half  a  grain  every  ten  minutes,  until  nausea  is  produced,  or, 
still  better,  probably,  by  bringing  the  patient  under  the 
anaesthetic  influence  of  ether  or  chloroform. 

As  in  other  dislocations,  the  reducing  forces  should  act 
gradually  and  steadily,  and  in  the  line  of  the  axis  of  the 
dislocated  bone,  and  during  their  operation,  the  patient's 
mind  should  be  interested,  if  possible,  in  some  subject  other 
than  his  accident. 

The  treatment  of  the  individual  dislocations  is  as  follows : — 

1st.  The  dislocation  upwards  on  the  dorsum  ilii.  The 
patient  is  placed  upon  a  table  covered  with  a  mattrass,  or 

(224) 


DISLOCATIONS    OF    THE    HIP-JOINT. 


225 


folded  blankets.  The  pelvis  is  fixed  by  means  of  a  sheet 
folded  longitudinally,  passed  under  the  perineum  and  over  the 
crista  of  the  ilium,  and  secured  to  a  staple  so  situated  that 
the  sheet  may  be  in  a  line  with  the  axis  of  the  thigh.  The 
extension  is  effected  through  the  intervention  of  a  wetted 
roller  secured  upon  the  lower  part  of  the  thigh,  and  having 
buckled  around  it  a  leathern  band  with  a  short  strap  on  each 
side  terminating  in  a  ring ;  the  two  rings  are  to  be  attached 
to  the  hook  of  the  pulleys,  and  the  latter  secured  to  a  staple 
in  such  a  position  that  the  extending  and  counter-extending 
forces  may  act  parallelly  to  each  other,  from  opposite  points, 
and  to  the  axis  of  the  bone.  Instead  of  the  leathern  band, 
a  double  towel  may  be  confined  to  the  thigh  by  the  clove-hitch. 
The  knee  of  the  dislocated  limb  should  be  bent  nearly  at 
right  angle  and  pointed  across  the  thigh  a  little  above  the 
knee  of  the  other  leg.  After  the  muscles  have  been  fatigued 
by  the  continued  action  of  the  pulleys,  the  surgeon  should 
grasp  the  knee,  and  rotate  the  hip  slightly  and  gently,  or  he 
may  pass  a  towel  around  the  upper  part  of  the  thigh,  and 
raise  thereby  the  head  of  the  bone,  when  it  will  usually  slip 
into  the  acetabulum,  (fig.  101). 

FIG.  101. 


The  subsequent  treatment  consists  in  keeping  the  patient 
in  bed  for  two  weeks  or  more,  his  knees  tied  to  each  other  by 
a  strip  of  muslin,  and  a  broad  belt  passed  around  his  pelvis 
pressing  upon  the  trochanters. 

2d.  The  dislocation  downwards,  or  into  the  foramen  ovale. 
To  reduce  this  luxation,  the  following  course  should  be  pur- 
sued :  The  patient  should  be  in  the  recumbent  position,  as  in 


226 


DISLOCATIONS    OF    THE    HIP-JOINT. 


FIG.  102. 


the  first  case ;  a  girth  made  of  leather,  or  of  a  sheet,  or 

towel,  should  be  passed 
around  the  upper  part  of 
the  thigh  and  attached  to 
one  oT  the  hooks  of  the 
pulleys,  the  other  being 
secured  to  a  staple  fixed 
in  the  wall  opposite  the 
dislocated  hip;  another 
girth  should  be  made  to 
encircle  the  pelvis,  so  as 
to  steady  the  body,  pass- 
ing the  noose  formed  by 
the  first  girth,  and  at- 
tached to  a  staple  placed 
opposite  to  the  first,  on 
the  sound  side  of  the 
patient.  The  cord  of 
the  pulleys  should  now 
be  drawn  until  the  head 
of  the  femur  begins  to 
leave  its  position  in  the 
foramen  ovale,  when  the 
surgeon  should  pass  his 
hand  behind  the  ankle 
of  the  sound  limb,  and 
grasp  the  other  ankle, 
which  he  draws  steadily 
towards  him ;  the  effect 

of  this  is,  to  throw  the  head  of  the  bone  outwards,  the  limb 
being  a  lever  with  its  fulcrum  on  the  extending  girth ;  as  soon 
as  the  head  of  the  femur  is  sufficiently  disengaged  from  its 
false  position,  the  extending  force  should  be  suspended,  when 
the  limb  will  be  restored,  (fig.  102.) 

The  after-treatment  is  as  in  the  first  case. 
3d.  To  reduce  the  dislocation  backwards,  or  into  the 
ischiatic  notch : — Secure  the  extending  and  counter-extending 
bands  as  in  the  first  species  of  luxation ;  then,  the  patient 
reposing  upon  his  sound  side,  the  knee  of  the  dislocated  limb 
should  be  pointed  across  the  middle  of  the  opposite  thigh, 
and  the  extension  practised  until  the  muscles  are  enfeebled ; 


DISLOCATIONS    OF    THE    HIP-JOINT.          227 

a  round  towel  should  now  be  passed  under  the  upper  part  of 
the  thigh,  and  over  the  shoulders  of  an  assistant,  who  should 
be  directed  to  press  upon  the  pelvis  with  his  hands,  and  at 
the  same  time  to  raise  his  shoulders :  thus  the  head  of  the 
femur  will  be  extricated  from  the  ischiatic  notch,  and  drawn 
downwards  into  the  acetabulum.  (Fig.  103.) 

FIG.  103. 


The  subsequent  treatment  does  not  differ  from  that  advised 
for  the  other  cases. 

4th.  To  restore  the  luxation  forwards  and  upwards,  or  on 
the  pubis : — The  apparatus  employed  is  the  same  as  has  been 
already  described,  and  its  mode  of  application  is  as  in  the 
last-named  variety  of  the  accident.  The  patient  should  be 
placed  upon  his  sound  side,  the  knees  widely  separated  from 
each  other,  and  the  extension  made  in  a  line  behind  the  axis 
of  the  body.  When  the  muscles  have  been  sufficiently 
fatigued,  a  round  towel  should  be  passed  under  the  upper 
part  of  the  thigh,  and  around  the  shoulders  of  an  assistant, 
who  elevates  the  head  of  the  femur  by  raising  his  shoulders, 
pressing  at  the  same  time  upon  the  pelvis.  (Fig.  104.) 

AFTER-TREATMENT. — The  same  as  in  the  other  varieties. 

A  very  good  and  simple  substitute  for  the  pulleys  has  been 
recently  recommended  by  Dr.  Gilbert,  Professor  of  Surgery 
in  the  Pennsylvania  Medical  College.  Its  mode  of  applica- 
tion is  thus  described  in  the  American  Journal  of  Medical 
Sciences,  vol.  ix.,  K  S. : — "  Place  the  patient  and  adjust  the 
extending  and  counter-extending  bands  as  for  the  pulleys ; 
then  procure  an  ordinary  bed-cord,  or  a  wash-line;  tie  the 


228          DISLOCATIONS    OF    THE    HIP-JOINT. 

FIG.  104. 


ends  together,  and  again  double  it  upon  itself,  pass  it  through 
the  extending  tapes  or  towel,  doubling  the  whole  once  more, 
and  fasten  the  distal  end,  consisting  of  four  loops  of  rope,  to 
a  window-sill,  door-sill,  or  staple,  so  that  the  cords  are  drawn 
moderately  tight ;  finally,  pass  a  stick  through  the  centre  of 
the  doubled  rope,  then  by  revolving  the  stick  as  an  axis,  or 
double  lever,  the  power  is  produced  precisely  as  it  should  be 
in  such  cases,  viz. :  slowly,  steadily,  and  continuously." 
(Fig.  105.) 

FIG.  105. 


Several  instances  of  anomalous  dislocations  of  the  head 
of  the  femur  are  recorded  by  Cooper  and  others.  (Sir  A. 
Cooper,  op.  cit.,  pp.  83-97.)  The  means  employed  in  the 


DISLOCATIONS    OF    THE    PATELLA.  229 

treatment  of  these  are  the  same  as  in  those  varieties  which 
have  been  already  described.  Proper  reflection  upon  such 
cases  will  enable  the  surgeon  to  determine  the  probable  posi- 
tion of  the  head  of  the  bone,  and  the  line  in  which  the  ex- 
tension and  counter-extension  should  be  made,  together  with 
such  other  expedients  as  will  assist  in  the  dislodgement  of 
the  head  of  the  bone  from  its  unnatural  position. 


SECTION  II. 
.DISLOCATIONS    OF    THE    PATELLA. 

The  patella  is  liable  to  displacement  in  two  directions, 
without  rupture  of  its  tendon  or  ligament,  viz. : 

1st.  Dislocation  outwards,  the  bone  resting  upon  the  exter- 
nal condyle  of  the  os  femoris,  causing  great  projection  at  this 
point,  and  an  inability  to  flex  the  knee. 

2d.  Dislocation  inwards,  producing  the  same  difficulty  in 
bending  the  knee,  with  a  marked  prominence  at  the  inner 
condyle  of  the  femur. 

The  restoration  is  generally  easily  accomplished,  by  re- 
laxing the  extensor  muscles  of  the  leg :  for  this  purpose  the 
heel  should  be  elevated  upon  the  shoulder  of  an  assistant, 
while  the  surgeon  presses  down  the  edge  of  the  patella 
which  is  most  removed  from  the  centre  of  the  knee-joint, 
thus  tilting  up  the  other  edge  of  the  bone,  when  the  mus- 
cles, aided  by  a  lateral  pressure,  will  draw  the  patella  to  its 
place. 

The  subsequent  treatment  consists  in  confining  a  straight 
splint  to  the  posterior  surface  of  the  limb,  and  in  making 
moderate  pressure  upon  the  knee  by  means  of  a  roller,  or  a 
laced  bandage ;  local  antiphlogistic  applications  are  gene- 
rally required,  in  addition.  The  patient  should  be  confined 
to  bed  for  about  two  weeks. 

20 


230         DISLOCATIONS    OF    HEAD    OF    FIBULA. 

SECTION  III. 
DISLOCATIONS    OF    THE    TIBIA  AT    THE    KNEE. 

Of  these  there  are  four  varieties,  viz. : 

1st.  Displacement  forwards, —  the  tibia  being  thrown  upon 
the  anterior  part  of  the  thigh,  of  which  the  condyles  are  de- 
pressed backwards,  and  somewhat  to  the  side.  (Cooper.) 

2d.  Backwards, —  the  tibia  drawn  upwards  behind  the  con- 
dyles of  the  femur,  which  project  very  much  on  the  front  of 
the  leg. 

3d.  Inwards, — the  internal  condyle  of  the  thigh-bone  rest- 
ing upon  the  external  semilunar  cartilage. 

4th.  Outwards, — the  inner  semilunar  cartilage  being  in  con- 
tact with  the  external  condyle  of  the  femur :  the  great  lateral 
projection  of  the  head  of  the  tibia  in  these  cases  renders  the 
diagnosis  of  the  injury  very  easy. 

These  dislocations  are  readily  reduced  by  making  exten- 
sion and  counter-extension  from  the  ankle  and  thigh,  con- 
joined with  moderate  pressure  upon  the  head  of  the  tibia. 
After  the  restoration  is  accomplished,  the  limb  should  be 
secured  to  a  straight  splint,  and  such  local  antiphlogistic 
means  should  be  employed  as  the  circumstances  of  each  case 
may  call  for.  The  patient  should  be  kept  in  bed  for  ten 
days  or  two  weeks,  or  longer,  if  there  be  continuance  of  pain 
or  of  inflammation. 

SECTION  IV. 
DISLOCATIONS   OF   THE   HEAD   OF   THE   FIBULA. 

The  head  of  the  fibula  is  sometimes  detached  from  its 
connexions  with  the  tibia,  and  drawn  backwards  by  the 
action  of  the  biceps.  It  is  easily  restored  to  its  place,  by 
flexing  the  leg  so  as  to  relax  this  muscle,  and  pressing  the 
bone  forwards. 

In  order  to  retain  it  "in  situ,"  the  leg  should  be  kept  bent 
over  a  pillow,  or  an  inclined  plane,  with  a  compress  bound 


DISLOCATIONS    OF    THE    ANKLE.  281 

dgainst  the  posterior  part  of  the  head  of  the  bone  by  means 
of  a  roller. 


SECTION    V. 
DISLOCATIONS    OP    THE    ANKLE. 

The  astragalus  may  be  separated  from  the  bones  of  the 
leg  in  four  directions,  viz. :  forwards,  backwards,  outwards, 
and  inwards.  The  recognition  of  the  accident  is  easy,  and 
the  reduction  not  difficult.  The  limb  should  be  flexed,  so 
as  to  relax  the  powerful  muscles  on  the  back  of  the  leg ; 
then,  while  extension  and  counter-extension  are  made  from 
the  foot  and  the  lower  part  of  the  thigh,  the  surgeon  should 
press  firmly  upon  the  dislocated  bone,  and  thus  force  it  to  its 
place. 

After  reduction,  the  leg  and  foot  should  be  confined  in 
carved  splints,  or  splints  made  of  binders'  board,  soaked  in 
hot  water  and  moulded  to  the  shape  of  the  limb,  with  a  foot- 
piece  at  right  angles;  or  a  fracture-box  will  be  found  to 
answer  equally  well.  This  confinement  to  bed  and  in  splints 
should  continue  for  five  or  six  weeks,  and  when  the  patient 
is  first  allowed  to  walk,  the  ankle  should  be  carefully  sup- 
ported by  a  roller  bandage,  or  a  firm  laced  gaiter.  The  time 
requisite  to  perfect  the  cure  of  these  accidents  is,  according  to 
Sir  A.  Cooper,  ten  or  twelve  weeks. 

If  the  fibula  alone  is  separated  from  the  tibia,  simple  late- 
ral pressure  will  restore  it  to  its  place,  after  which  a  roller 
and  compress  should  be  employed  for  some  weeks  to  retain  the 
bones  in  apposition ;  rest  is  necessary,  as  in  the  last-described 
injury. 

The  remarks  made  on  the  treatment  of  dislocations  of  the 
bones  of  the  hand  and  wrist  are  applicable  to  the  same  kinds 
of  injury  of  the  foot ;  the  treatment  to  be  pursued  in  the  re- 
duction, and  subsequently,  is  similar,  excepting  that  a  greater 
degree  of  force  is  required  to  reduce  the  luxation,  and  a  longer 
confinement  afterwards,  when  the  foot  is  involved  than  when 
the  hand  is  injured. 


CHAPTER  IV. 

COMPOUND    DIS  LOCATIONS. 

THESE  accidents  require  the  same  sort  of  treatment  as  com- 
pound fractures.  Much  experience,  and  careful  examination 
of  all  the  circumstances  connected  with  each  case,  are  neces- 
sary to  enable  the  surgeon  to  determine  when  to  attempt  to 
save  a  limb  so  injured,  and  when  to  amputate.  This  volume 
does  not  pretend  to  lay  down  rules  for  such  cases.  The 
reader  will  do  well  to  consult  the  works  of  the  Coopers,  Vidal 
(de  Cassis),  Boyer,  Chelius,  and  others,  with  reference  to  this 
important  subject. 

If  an  attempt  to  save  the  limb  be  decided  on,  the  wound 
should  be  carefully  cleansed,  all  foreign  bodies,  spicula,  or 
small  and  detached  fragments  of  bone,  removed,  hemorrhage 
arrested,  and  the  dislocated  bone  restored,  if  possible.  Then 
the  edges  of  the  wound  should  be  apposed  to  each  other,  and 
covered,  as  in  the  case  of  compound  fractures  of  the  patella, 
&c.,  with  a  piece  of  lint  dipped  in  blood,  or  in  some  aggluti- 
native fluid,  and  every  effort  should  be  made  to  convert  the 
injury  into  a  simple  dislocation.  The  tendency  to  re-dis- 
placement should  be  overcome  by  placing  the  limb  in  such  a 
position  as  shall  relax  the  most  powerful  muscles  connected 
with  the  dislocated  bone,  and  by  the  application  of  a  bandage 
to  make  moderate  compression  upon  the  seat  of  injury  and 
on  the  implicated  muscles.  The  disposition  to  inflammation, 
or  this  condition  itself,  should  be  combated  by  leeches,  occa- 
sionally by  general  bleeding,  by  irrigation  with  cold  water, 
by  evaporating  lotions,  and  by  position.  Warm  applica- 
tions should  be  avoided,  so  long  as  there  is  any  prospect  of 
closing  the  wound  by  direct  union.  Perfect  rest  should  be 
maintained  in  bed,  if  one  of  the  lower  extremities  be  involved, 
and  such  splints  and  other  retentive  and  supporting  appli- 
ances should  be  employed  as  will  most  conduce  to  the  objects 
in  view. 

.(232) 


APPARATUS    FOE    RELIEF    OF    ANCHYLOSIS.      233 


APPARATUS   FOR  THE   RELIEF   OF   PARTIAL  ANCHYLOSIS. 

It  not  unfrequently  happens  after  fractures  involving  a 
joint,  dislocations,  and  other  injuries  or  diseases,  that  the  mo- 
tion of  the  joint  is  very  much  impaired,  and  the  usefulness  of 
the  whole  limb  much  diminished.  The  difficulty  may  often  be 
entirely  relieved  or  lessened,  by  adapting  to  the  limb  some 
instrument,  whereby 

constant  and   gradu-  FlG- 106- 

ally  increasing  mo- 
tion may  be  given  to 
the  joint  for  a  length 
of  time.  The  accom- 
panying drawing  (fig. 
106)  exhibits  an  ap- 
paratus of  this  kind 
for  the  arm,  which  is 
recommended  by  Pro- 
fessor Mutter,  in  his 
edition  of  Mr.  Lis- 
ton's  u  Lectures  on 

the  Operations  of  Surgery,"  &c.,  (p.  433,  Am.  edit.,  1846.) 
It  consists  of  steel  splints  curved  to  the  shape  of  the  arm  and 
fore-arm,  and  well  padded,  two  for  the  upper  arm  and  two  for 
the  fore-arm,  for  the  anterior  and  posterior  surfaces  of  the 
limb.  The  anterior  splints  are  connected  by  a  steel  or  iron 
bar,  which  is  firmly  secured  to  them  on  each  side,  and  jointed 
by  a  pivot  &t  the  centre,  so  as  to  move  freely  like  a  hinge. 
A  "  Stromeyer's  screw"  is  fastened  to  the  centre  of  the  same 
splints  in  front,  by  moving  which  the  apparatus  may  be  made 
straight  or  angular,  at  pleasure.  The  splints  are  now  applied 
to  the  limb,  those  for  each  division  of  the  member  being  se- 
cured to  each  other  by  means  of  straps  and  buckles,  and  thus 
made  to  surround  the  arm  above  and  below  its  bend,  care  be- 
ing had  that  the  joint  of  the  side  bars  is  opposite  the  centre 
of  motion  of  the  elbow.  When  the  apparatus  is  thus  properly 
applied,  the  screw  should  be  turned  until  the  patient  com- 
mences to  experience  slight  uneasiness  in  the  joint ;  this  pro- 
cess should  be  repeated  daily,  now  extending  and  now  flexing 


234      APPARATUS    FOR    RELIEF    OF    ANCHYLOSIS. 

the  limb, — avoiding  the  infliction  of  pain  in  the  joint, — until 
an  adequate  degree  of  motion  is  restored :  the  action  of  the 
apparatus  will  be  very  much  aided  by  frequently  soaking  the 
joint  in  warm  water. 

When  so  elegant  a  splint  as  that  employed  by  Dr.  Mutter 
cannot  be  obtained,  the  same  effect  may  be  had  by  attaching 
the  screw  to  simple  splints  of  wood.  The  apparatus  may  be 
adapted  to  the  knee  as  well  as  to  the  elbow,  and  with  equally 
good  results.  • 


PART    V. 

ON  SOME  OF  THE  MINOR  SURGICAL  OPERATIONS. 
CHAPTER  I. 

ON  INCISIONS. 

WE  cannot  attach  much  importance  to,  or  advise  any  one 
to  comply  with,  set  rules  for  the  mode  of  holding  and  using 
cutting  instruments.  We  believe  that  each  can  judge 
best  for  himself  in  such  matters ;  and  that  the  most  rational 
proposition  is  that  each  one  shall  use  his  knife  in  such  a 
manner  as  will  enable  himself  to  gain,  most  readily  and  satis- 
factorily, the  object  which  he  has  in  view.  Nevertheless,  a 
few  observations,  offered  as  suggestions,  may  not  be  amiss 
touching  the  simple  incisions  of  Minor  Surgery. 

In  the  first  place,  the  cutting  edge  of  the  instrument  to  be 
used  should  be  sharp.  And  it  is  important  that  the  surgeon, 
especially  if  he  reside  in  the  country,  remote  from  his  cutler, 
shall  be  able  to  keep  his  knives  in  good  order.  For  this  end 
he  must  have  a  proper  hone ;  one  of  the  "  Water  of  Ayr" 
stones  of  Scotland,  or  an  Arkansas  or  Missouri  stone,  will 
answer  the  purpose.  In  making  use  of  it,  its  surface  should 
be  moistened  with  olive  oil,  and  the  knife  passed  lightly  over 
it  from  heel  to  point,  the  back  being  slightly  raised  from  the 
stone,  and  equally,  of  course,  on  both  sides  of  the  blade. 
After  the  instrument  has  been  honed  until  its  cutting  edge  is 
smooth  and  sharp,  it  may  be  strapped,  or  not,  as  seems  re- 
quisite ;  but  if  the  hone  be  sufficiently  fine,  strapping  will  not 
be  necessary. 

Fancy  has  been  very  busy  in  contriving  a  variety  of  shapes 
for  the  simple  scalpel;  the  one  which  we  have  before  spoken 
of,  (fig.  2,)  will  be  found  as  advantageous  as  any.  It  is 
usually  held  between  the  thumb  and  the  first  two,  sometiqges 
the  first  three,  fingers  of  the  right  hand.  If  the  incisions  are 
to  be  small  in  extent,  and  require  to  be  delicately  and  care- 
fully made,  the  knife  may  be  held  as  indicated  in  fig.  107, 
the  hand  being  steadied,  if  necessary,  by  the  little  finger  or 

(236) 


236 


ON    INCISIONS 
FIG.  107. 


•wrist  resting  upon  the  part  to  be  operated  upon.  If  rapid 
and  extensive  incisions  are  to  be  made,  and  if  the  operator 
be  practised,  the  instrument  may  be  best  held  as  shown  in 
fig.  108 ;  but  the  position  must  be  varied  according  to  cir- 


FIG.  108. 


cumstances.  For  example,  if  the  surgeon  be  about  to  sever 
rugged  and  partially  detached  portions  of  a  flap,  or  to  pare 
the  edges  of  a  lacerated  wound,  he  will  find  it  most  conve- 
nient, probably,  to  use  the  knife  as  illustrated  in  the  accom- 
panying drawing  (fig.  109) ;  if  he  wishes  to  open  an  abscess, 


FIG.  109. 


ON    INCISIONS. 


23T 


he  may  employ  "  Syme's  abscess  lancet,"  a  curved  blade, 
with  a  sharp  point  and  a  double  cutting  edge,  as  delineated  in 
fig.  Ill,  or  he  may  plunge  a  common  sharp-pointed  bistoury 
through  the  integuments,  as  in  fig.  110. 


FIG.  no. 


The  direction  of  the  incision  to  be  made  should  depend 
upon  the  object  to  be  gained.  If  it  be  desired  merely  to 
divide  the  parts,  the  cut  is  usually  made  in  a  straight  line,  the 
knife  being  entered  perpendicularly  to  the  surface,  the  wrist 
then  depressed,  and  the  edge  of  the  instrument  drawn  along 
in  contact  with  the  skin ;  when  the  requisite  extent  of  divi- 
sion has  been  gained,  the  wrist  should  be  elevated,  and  the 
knife  withdrawn  perpendicular  to  the  skin.  Or  if  the  parts 
be  loose  enough,  the  integuments  may  be  pinched  up  between 
the  thumb  and  fore-finger,  and  a  sharp-pointed,  narrow- 
bladed  bistoury,  straight  or  curved,  may  be  thrust  through 
the  base  of  the  fold,  and  made  to  cut  its  way  upwards  at  the 
same  time. 


238  ON    INCISIONS. 

A   semilunar  incision  is  sometimes  performed  by  sweep- 
ing the  edge  of  the  knife  through  the  skin  in 
IG*      '     a  semicircular  direction. 

Sometimes  it  is  advisable  to  make  a  crucial 
division  of  the  soft  parts,  two  straight  incisions 
crossing  each  other  at  right  angles.  (Fig.  112.) 

If  it  be  desired  to  remove  a  portion  of  the  in- 
teguments, as  in  the  extirpation  of  a  considerable  tumour, 
"where  otherwise  there  would  be  a  redundancy  of  covering,  an 

elliptical  incision  is'made,  by 
FlG- 113-  uniting  two  semilunar  cuts  at 

their  extremities.  (Fig.  113.) 
Judgment  must  be  used  in  per- 
forming this  division  ;  the  con- 
tractility of  the  parts  is  such 
that,  under  ordinary  circum- 
stances, the  resulting  wound  will  gape  much  more  widely  than 
the  amount  of  tissue  abstracted  will  account  for.  It  is  better, 
therefore,  to  take  away  too  little  than  too  much ;  in  the 
former  event,  time  will  diminish  the  difficulty,  and  pressure 
carefully  employed  will  generally  obviate  any  unpleasant 
effect ;  in  the  latter  case,  the  edges  of  the  wound  cannot  be 
brought  together,  excepting  by  so  much  straining  as  will  be 
painful,  and  endanger  inflammation. 

Other  incisions  are  represented  in  figs.  114,  115,  116,  and 
117 ;  names  are  applied  to  them  corresponding  to  the  letters 

FIG.  114.  FIG.  115.  FIG.  116.  FIG.  117. 


V 


which  in  shape  they  resemble.  They  are  designed  to  facili- 
tate the  exposure  of  the  parts  beneath  the  surface,  the  flaps 
of  the  integument  being  elevated  for  the  time,  and  then  re- 
placed,  and  their  margins  made  to  unite. 

The  direction  of  the  incision  should  depend  somewhat,  too, 
upon  the  situation  of  the  part.  Thus,  on  the  face  or  neck, 
especially  of  a  female,  it  is  desirable  that  no  unsightly  scar 
should  remain ;  this  end  may  be  gained,  to  a  certain  extent, 


ON    INCISIONS.  239 

by  dividing  the  skin  in  a  line  parallel  to  the  direction  of  the 
fibres  of  the  subjacent  muscle.  If  it  be  advisable  that  the 
margins  of  the  wound  shall  close  readily,  the  skin  must  be 
divided  in  the  manner  just  indicated :  if  it  be  preferred  that 
ihe  wound  shall  remain  open,  the  incision  should  be  more  or 
less  directly  transverse  to  the  course  of  the  muscular  fibres. 

It  is  often  necessary  to  prolong  an  incision  of  the  integu- 
ments beyond  the  point  at  which  the  eye  can  direct  the  in- 
strument. In  such  cases  it  is  important  to  have  a  guide  upon 
which  the  knife  may  be  glided.  For  this  purpose,  the  finger 
answers  very  well  sometimes,  as  when  the  side  of  a  hernial 
stricture  is  to  be  divided,  the  fore-finger  of  the  left  hand 
may  be  passed  as  high  up  as  possible,  and  the  bistoury  slid  in 
upon  it  (fig.  118,) ;  or,  instead  of  a  finger,  a  grooved  director 

1     FIG.  118. 


may  be  first  introduced,  and  the  bistoury  then  pushed  along 
its  furrow,  as  is  usually  done  when  successive  layers  of  tissue 
are  to  be  divided. 

Subcutaneous  wounds  or  incisions  have,  within  a  few  years 
past,  come  into  merited  esteem,  because  they  enable  the  sur- 
geon to  effect  even  extensive  division  of  parts  without  ex- 
posing them  to  the  air,  and,  as  a  consequence,  union  takes 
place  without  inflammation  and  very  promptly.  These  inci- 
sions may  be  accomplished  thus :  if  the  object  be  to  divide  a 
tendon,  or  to  open  a  joint,  a  fine,  sharp-pointed  knife,  such  as 
is  represented  in  fig.  119,  must  be  introduced  through  the  in- 

FIG.  119. 


240  ON  iNc 

tegument,  obliquely,  at  a  little  distance  from  the  deeper  point 
to  be  divided,  and  pushed  on  to  the  latter ;  now  the  point  of 
the  knife  should  be  depressed  and  its  edge  a  little  turned 
towards  the  surface  to  be  cut,  and  the  division  of  this  effected 
as  by  stealth,  to  use  the  expression  of  Mr.  Miller.  The  in- 
strument must  be  carefully  withdrawn  as  it  was  entered,  and 
the  external  orifice  immediately  closed  by  adhesive  plaster,  or 
covered  with  a  piece  of  lint  soaked  in  collodion,  and  perfect 
quietude  of  the  part  enjoined.  A  narrow-bladed  knife,  like 
that  shown  in  the  accompanying  drawing,  (fig.  120,  taken 

FIG.  120. 


from  Mr.  Erichsen's  book,)  having  only  a  part  of  the  blade 
sharp,  the  remainder  rounded,  will  answer  very  well  for  such 
sections. 

Another  method  of  making  incisions  of  deep-seated  parts, 
so  as  to  avoid  access  of  air,  is  as  follows :  pinch  up  a  fold  of 
the  integuments  covering  the  part  to  be  operated  upon,  and 
enter  a  sharp-pointed  knife  more  or  less  perpendicularly  at 
the  base  of  the  fold;  after  the  desired  section  has  been  made, 
withdraw  the  blade  carefully,  and  allow  the  integuments  to 
regain  their  proper  position,  then  cover  the  opening  in  the 
skin  as  above  directed.  This  is  a  convenient  mode  of  open- 
ing chronic  abscesses,  when  one  does  not  wish  to  evacuate  all 
the  matter  at  once. 

For  more  detailed  instructions  upon  these  matters,  which 
we  have  not  thought  it  necessary  to  furnish  here,  the  reader 
may  consult  any  good  work  on  Operative  Surgery,  as  Mal- 
gaigne's,  Dr.  Henry  Smith's,  or  Mr.  Fergusson's ;  from  the 
latter,  particularly,  we  have  drawn  most  of  the  illustrations 
and  suggestions  contained  in  this  short  chapter. 


CHAPTER  II. 

ON    BLOODLETTING. 

BLOOD  may  be  drawn  from  a  vein  or  artery  of  some  size, 
constituting  what  is  termed  "general  bleeding,"  or  from  the 
smallest  vessels  which  ramify  beneath  the  surface,  by  means 
of  cups  and  leeches,  "local  bleeding."  The  former  method 
of  abstracting  blood  is  practised  when  the  amount  to  be  drawn 
is  considerable,  or  when  a  general  depressing  effect  upon  the 
system  is  desirable ;  the  latter,  when  a  particular  part  only 
of  the  economy  is  affected, — the  system  generally  being  little, 
or  not  at  all,  involved.  Sometimes,  however,  the  indications 
for  resorting  to  both  operations  exist  in  the  same  case  and  at 
the  same  time :  under  such  circumstances,  both  general  and 
local  bloodletting  should  be  practised,  the  former  from  a  vein, 
usually,  the  latter  from  the  vicinity  of  the  suffering  organ. 

In  cities,  these  operations  are  generally  performed  by  a 
class  of  persons  who  devote  themselves  to  this  duty  as  an  oc- 
cupation. In  the  country,  the  practitioner  himself  must 
attend  to  them.  Every  medical  man,  however,  should  be 
well  acquainted  with  the  methods  of  operating,  and,  whether 
he  live  in  the  city,  or  in  the  country,  should  be  skilled  in  the 
practice  of  general  bleeding,  at  least,  since  he  will  be  often 
compelled  to  resort  to  it. 


SECTION  I. 
ON  THE  OPERATIONS  FOR  GENERAL  BLEEDING. 

These  consist  in  the  opening  of  a  vein  or  an  artery ;  the 
former  is  much  the  most  commonly  practised,  and  should 
always  be  preferred,  if  a  choice  can  be  made.  The  incision 
of  a  vein  is  termed  phlebotomy;  that  of  an  artery, 
arteriotomy. 

PHLEBOTOMY.  — 1.  One  of  the  veins  at  the  bend  of  the 
21  (241) 


242 


ON    THE    OPERATIONS 


arm  is  usually  selected  for  bleeding,  because  these  vessels  are 
very  superficial  and  convenient  of  access  in  this  region,  and 
are  of  sufficient  size  to  allow  the  requisite  amount  of  blood  to 
escape  freely  and  rapidly.  The  annexed  drawings  give  a  very 
good  view  of  the  veins  of  this  region,  as  they  are  generally 
distributed,  with  their  positions  relatively  to  the  artery  and 
the  superficial  nerves  (figs.  121  and  122).  In  figure  121  are 


FIG.  121. 


FIG.  122. 


displayed:  "  1,  the  radial  vein;  2,  the  cephalic  vein;  3,  the 
anterior  ulnar  vein  ;  4,  the  posterior  ulnar  vein  ;  5,  the  trunk 
formed  by  their  union  ;  6,  the  basilic  vein,  piercing  the  deep 
fascia  at  7  ;  8,  the  median  vein ;  9,  a  communicating  branch 
between  the  deep  veins  of  the  fore-arm  and  the  upper  part 
of  the  median  vein ;  10,  the  median  cephalic  vein ;  11,  the 
median  basilic ;  12,  a  slight  convexity  of  the  deep  fascia, 
formed  by  the  brachial  artery.  This  fascia  is  divided  and 
turned  aside  in  fig.  122,  to  show  the  brachial  artery ;  13,  the 
process  of  fascia,  derived  from  the  tendon  of  the  biceps 
muscle,  and  separating  the  median  basilic  vein  from  the  bra- 


FOR    GENERAL    BLEEDING.  243 

chial  artery ;  14>  the  external  cutaneous  nerve,  piercing  the 
deep  fascia  and  dividing  into  two  branches  which  pass  behind 
the  median  cephalic  vein ;  15,  the  internal  cutaneous  nerve, 
dividing  into  branches  which  pass  in  front  of  the  median 
basilic  vein ;  16,  the  intercosto-humeral  cutaneous  nerve  ;  17, 
the  spiral  cutaneous  nerve,  a  branch  of  the  musculo-spiral." 
Druitt,  p.  494. 

The  median  cephalic  and  the  median  basilic  veins  are  those 
in  which  the  incision  is  generally  practised  in  bleeding.  The 
median  basilic  is  the  larger  of  the  two,  and  would  seem  there- 
fore to  be  the  most  proper  for  the  operation,  and  it  is  also 
more  superficial  than  the  other ;  but  the  brachial  artery  is 
situated  very  near  it,  passing  beneath  it  from  the  external 
side,  and  separated  from  it  only  by  the  thin  aponeurosis  from 
the  tendon  of  the  biceps  muscle,  so  that  an  incision  too  deep 
would  probably  penetrate  the  artery  as  well  as  the  vein,  as 
has  not  unfrequently  happened  ;  moreover,  this  vein  is  crossed 
in  front  by  several  filaments  of  the  internal  cutaneous  nerve, 
which,  as  they  are  invisible  to  the  operator,  are  liable  to  be 
involved  in  his  incision.  Therefore  it  is  safer  to  open  the 
median  cephalic  vein,  as  this  is  remote  from  the  artery ;  and 
as  regards  the  liability  of  wounding  one  of  the  nervous  fila- 
ments, the  danger  is  rather  less  than  in  the  other  case,  the 
external  cutaneous  nerve  passing  beneath  it ;  the  superior 
part  of  this  vein,  according  to  M.  Lisfranc,  is  never  crossed 
by  nervous  twigs.  With  regard  to  injury  of  the  nerves  in 
bleeding  at  the  elbow,  M.  Velpeau  says,  that  "  all  the  veins 
at  this  part  of  the  arm  are  surrounded  by  nervous  filaments, 
and  that  with  reference  to  this  point,  it  would  be  ridiculous 
to  open  one  in  preference  to  any  other."  (Op.  cit.,  p.  293.) 
Probably  the  best  rule  is,  to  bleed  from  the  median  cephalic 
vein,  provided  it  is  sufficiently  large  to  allow  the  blood  to  flow 
with  freedom.  If  the  median  basilic  be  selected,  the  incision 
should  be  made,  if  possible,  either  above  or  below  the  point 
at  which  the  vein  crosses  the  artery,  and  not  directly  over 
the  latter,  the  artery  becoming  more  deeply  situated  as  it 
leaves  the  vein.  Sometimes  the  artery  runs  parallel  with  this 
vein ;  in  such  cases  the  fore-arm  should  be  forced  into  a  state 
of  pronation,  so  that  the  tendon  of  the  biceps  shall  be  made 
to  intervene  between  the  two. 

In  all  cases,  the  operator  should  carefully  examine  the  part 


244  ON    THE    OPERATIONS 

to  see  that  there  is  no  anomalous  distribution  of  the  arteries, 
and  to  guard  against  danger  from  this  cause. 

It  often  occurs  that  in  females  and  in  children,  the  veins 
are  scarcely,  if  at  all,  visible,  the  adipose  tissue  being  so 
abundant.  Sometimes  they  may  be  made  apparent,  by  allow- 
ing the  ligature  to  compress  the  arm  above  the  elbow  for  a 
considerable  time,  by  plunging  the  fore-arm  in  warm  water, 
by  friction  of  the  member,  and  by  directing  the  patient  to 
call  the  muscles  of  the  hand  and  fore-arm  into  action.  Gene- 
rally, however,  if  the  veins  cannot  be  seen,  they  may  be  felt 
beneath  the  surface,  like  round  elastic  cords,  not  pulsating  as 
the  artery,  and  losing  their  prominent  corded  form,  and  their 
elasticity,  when  the  compression  is  removed  and  the  blood 
permitted  to  flow  along  its  channels,  regaining  these  charac- 
teristic marks  when  the  pressure  is  resumed  ;  the  tendon  of 
the  biceps  has  been  mistaken  for  a  deep-seated  vein,  and  has 
been  cut  in  attempts  to  bleed ;  such  an  error  ought  never  to 
occur,  as  apart  from  the  criteria  above  mentioned  for  distin- 
guishing a  vein,  the  tendon  may  be  easily  recognized  by 
flexing  the  fore-arm  and  marking  the  increased  prominence 
which  it  thereby  acquires. 

Before  opening  the  vein,  the  surgeon  should  procure,  and 
hav§  arranged  in  some  convenient  position,  a  narrow  strip  of 
muslin,  or  linen,  with  which  to  arrest  the  circulation  in  the 
veins  of  the  fore-arm ;  a  lancet ;  a  vessel  to  receive  the  blood 
as  it  flows  from  the  incision ;  a  basin  of  water  and  a  towel,  to 
cleanse  the  surface  after  the  operation ;  a  small  compress  of 
linen  folded,  to  be  placed  over  the  wound,  and  a  narrow  ban- 
dage of  muslin,  or  linen,  to  retain  this  in  place ;  smelling- 
salts,  or  some  other  restorative,  should  also  be  at  hand. 

The  position  of  the  patient  during  the  operation  is  a  matter 
of  some  consequence.  If  it  is  desirable  to  abstract  a  large 
quantity  of  blood,  the  recumbent  posture  should  be  assumed, 
as  syncope  occurs  less  speedily  in  this  than  in  any  other 
position ;  when  a  rapidly  prostrating  or  relaxing  effect  is  re- 
quired, as  in  cases  of  hernia  or  dislocation  of  the  hip,  the 
patient  should  stand  up  while  the  blood  is  flowing ;  when  an 
ordinary  depletion  only  is  indicated,  and  other  circumstances 
permit  of  it,  the  sitting  posture  will  be  found  the  most  con- 
venient. The  size  of  the  opening,  too,  should  be  varied  in 
different  cases  to  meet  particular  views ;  as,  for  example, 


FOR    GENERAL    BLEEDING.  245 

when  a  prompt  effect  is  desired,  the  incision  should  be  long, 
to  allow  the  blood  to  escape  in  a  full  current ;  a  small  open- 
ing should  be  made  when  a  gradual  influence  is  intended  to 
be  produced. 

The  choice  of  the  arm  on  which  to  practise  the  operation 
may  be  left  to  the  surgeon's  discretion  ;  sometimes  the  veins 
are  larger  in  one  arm  than  in  the  other,  and  their  relative 
position  with  regard  to  the  artery  may  be  more  favourable  in 
one  than  in  the  other.  If  there  be  no  reason  of  this  kind  for 
selecting  the  right  arm,  it  will  be  better  to  bleed  from  the 
left,  since,  if  any  accident  should  happen,  the  injury  is  more 
easily  submitted  to  in  the  latter  than  in  the  former. 

Either  the  thumb-lancet,  or  the  spring-lancet,  may  be  used 
according  to  the  habit  or  the  fancy  of  the  operator ;  some 
prefer  one,  some  the  other,  and  occasionally  a  patient  is  met 
with  who  has  strong  objections  against  one  or  the  other. 
There  seems  to  be  great  diversity  of  opinion  concerning  the 
comparative  safety  of  the  two  instruments.  It  is  urged  in 
favour  of  the  use  of  the  spring-lancet,  that  the  operation  is 
done  more  instantaneously  with  it  than  with  the  other,  and 
with  less  pain ;  and  that  it  is  less  frequently  attended  with 
wound  of  the  artery,  in  those  cases  in  which  the  vein  is 
entered  at  a  point  directly  over  this  vessel ;  this  last  argument 
derives  strong  support  from  the  statement  of  Dr.  Reese,  the 
American  editor  of  Cooper's  Surgical  Dictionary,  to  the  eifect 
that  aneurism  of  the  brachial  artery  at  the  bend  of  the  arm 
is  much  more  commonly  met  with  in  the  northern  and  eastern 
sections  of  this  country,  where  the  thumb-lancet  is  in  general 
use,  than  in  the  southern  and  western  and  middle  states, 
where  the  spring-lancet  is  employed  very  generally,  and  in 
many  districts  by  very  ignorant  persons,  as  by  the  slaves  on 
the  southern  plantations.  The  thumb-lancet  is  the  most  sur- 
gical instrument ;  when  of  the  proper  shape  and  in  perfectly 
good  order,  as  it  always  should  be,  the  vein  may  be  opened 
with  sufficient  quickness,  and  with  no  more  pain  than  when 
the  spring-lancet  is  employed  ;  the  size  of  the  incision  can  be 
more  nicely  graduated  with  the  former  than  with  the  latter, 
and  a  deep-seated  vein  may  be  more  certainly  reached  with 
it :  and  as  to  the  danger  of  penetrating  the  posterior  wall  of 
the  vein  and  wounding  the  subjacent  artery,  if  the  thumb- 
lancet  is  used,  the  same  amount  of  practice  is  as  requisite  to 
21* 


246  ON    THE    OPERATIONS 

enable  the  operator  to  determine  just  how  far  from,  or  how 
near  to,  the  skin  it  is  necessary  to  hold  the  fleam  of  the 
spring-lancet,  in  order  that  he  may  open  the  vein  merely  and 
not  penetrate  entirely  through  it,  will  render  him  capable  of 
detecting,  by  the  diminution  in  the  resistance  offered  to  the 
point  of  the  thumb-lancet,  the  moment  at  which  the  cavity  of 
the  vessel  has  been  entered  by  the  instrument.  It  has  occa- 
sionally happened  in  bleeding  with  the  spring-lancet,  that  the 
fleam,  or  blade,  of  the  instrument  has  been  broken  off,  by  the 
force  of  the  spring,  and  has  remained  in  the  cavity  of  the 
vein,  rendering  it  necessary  in  some  instances  to  slit  open  the 
vessel  as  far  as  the  first  valve,  in  order  to  remove  the  lancet. 
This  accident  is  of  rare  occurrence,  but  the  possibility  of  such 
an  incident  should  be  borne  in  mind.  The  spring-lancet  will 
be  found  the  most  convenient  instrument  in  bleeding  children, 
in  consequence  of  the  struggles  which  they  usually  make,  and 
•which  interfere  very  much  with  the  performance  of  the  opera 
tion  when  the  thumb-lancet  is  used. 

The  shape  of  the  blade  varies  very  much  according  to  the 
fancy  of  the  surgeon,  or  of  his  cutler ;  we  would  recommend 
one  rather  more  oval-shaped  at  the  point  than  that  repre- 
sented in  fig.  123.  The  point  and  the  edges  of  the  instru- 
ment should  be  very  sharp,  and  the  blade  as  thin  as  is  com- 
patible with  perfect  strength  and  security.  The  lancet  used 
for  bleeding  should  never  be  employed  for  any  other  pur- 
pose, as  cases  have  often  occurred  of  inoculation  of  the 
wound  with  irritating  or  poisonous  matters  which  have  ad- 
hered to  the  blade.  The  instrument  should  be  well  cleansed 
and  wiped  dry  after  it  has  been  in  requisition,  and  kept  in  a 
suitable  case. 

OPERATION.  —  The  operation  is  commenced  by  encircling 
the  arm,  at  a  point  an  inch  or  two  above  the  elbow,  by  a 
piece  of  ribbon,  or  a  strip  of  muslin,  an  inch  and  a  half  wide 
and  a  yard  and  a  half  long.  The  arm  should  be  bared 
nearly  to  the  shoulder,  care  being  had  that  the  sleeve  of  the 
patient's  dress  exercises  no  constriction  about  the  limb,  im- 
peding the  flow  of  the  blood  through  the  artery ;  then  the 
surgeon,  having  carefully  examined  the  bend  of  the  arm,  in 
order  to  ascertain  the  precise  position  of  the  brachial  artery, 
and  whether  there  be  any  anomalous  distribution  of  the  ves- 
sels, places  the  centre  of  the  compressing  bandage  upon  the 


FOR    GENERAL    BLEEDING.  247 

middle  of  the  arm,  at  the  point  already  indicated,  carrying 
the  tails  around  on  each  side  successively,  and  bringing  them 
up  over  the  anterior  face  of  the  arm,  to  tie  them  in  a  single 
bow-knot  on  its  outer  side,  the  extremities  of  the  band  hang- 
ing downwards.     The  bandage  should  be  applied  sufficiently 
tight  to  arrest  the  course  of  the  blood  in  the  superficial  veins, 
but  not  to  interfere  with  the  circulation  in  the  artery.     If,  as 
is  sometimes  the  case,  the  veins  do  not  swell,  the  expedients 
before  adverted  to  should  be  tried,  and  if  these  are  ineffectual, 
the  other  arm  should  be  taken,  or  a  vein  in  some  other  part 
of  the  body  may  be  opened,  if  it  should  be  impossible  to  find 
a  suitable  vein  in  either  arm.     In  such  circumstances,  M.  Lis- 
franc  advises  that  the  cephalic  vein  should  be  exposed,  where 
it  occupies  the  interstice  between  the  deltoid  and  pectoralis- 
major  muscles,  and  an  incision  made  in  it.     But  there  are 
few  instances  in  which  it  is  not  possible  to  abstract  the  requi- 
site amount  of  blood  from  one  of  the  veins  at  the  bend  of  the 
arm.     The  vein  having  been  selected  for  the  operation,  and 
the  exact  situation  of  the  artery  with  reference  to  it  ascer- 
tained, the  next  step  is  to  make  the  incision.     It  is  of  great  im- 
portance that  the  patient's  arm  shall  be  well  secured,  in  order 
to  avoid   any  accident  which   might  ensue  from  a  sudden 
movement  of  the  limb,  as  the  instrument  pierces  the  tissues ; 
this  is  of  less  moment  when  the  spring-lancet  is  employed, 
than  if  the  thumb-lancet  is  used.     When  the  latter  instru- 
ment is  selected,  the  operator  will  find  it  of  much  advantage 
to  be  equally  skilful  with  his  right  and  left  hands,  as  he  can 
secure  the  patient's  arm,  and  perform  the  operation  more 
satisfactorily.     Thus,  the  arm  should  be  thrown  out  from  the 
body,  and  the  surgeon  should  sit,  or  stand,  between  the  limb 
and  the  side  of  the  patient :  if  the  right  arm  is  to  be  operated 
upon,  the  elbow  should  be  supported  upon  the  outstretched 
fingers  of  the  surgeon's  left  hand,  his  thumb  pressing  upon 
the  vein,  about  an  inch  below  the  point  of  incision,  in  order 
to  steady  the  vessel,  and  to  prevent  a  too  great  out-gush  of 
blood  from  soiling  the  clothes,  while  the  patient's  fore-arm 
and  hand  are  extended  beneath  the  left  fore-arm  of  the  ope- 
rator, and  thus  securely  held ;  the  lancet  is,  of  course,  entered 
with  the  right  hand :  if  a  vein  of  the  left  arm  is  to  be  opened, 
the  surgeon  modifies  his  position,  so  as  to  secure  the  arm  with 
his  own  right  hand  and  arm,  and  holds  the  instrument  in  his 


248  ON    THE    OPERATIONS 

left  hand.  But  if,  as  is  the  case  with  most  persons,  the  ope- 
rator cannot  make  the  incision  conveniently  with  his  left  hand, 
he  must  j)lace  himself  on  the  outer  side  of  the  patient's  left 
arm,  securing  the  fore-arm  with  his  own  left,  and  open  the 
vein  with  his  right  hand. 

The  blade  of  the  lancet  should  be  exposed  so  as  to  form 

a  slightly  obtuse  angle 

FIG.  123.  with    the   handles,   and 

held  as  is  represented 
in  the  annexed  drawing, 
(fig.  123,)  being  grasped 
near  its  head  between 
the  extremities  of  the 
surgeon's  thumb  and 
fore-finger,  the  handle 
resting  against  the  lat- 
ter. The  operator  places 

his  middle  finger  upon  the  patient's  fore-arm,  as  in  the  figure, 
so  as  to  support  the  hand :  the  point  of  the  lancet  is  entered 
perpendicularly  to  the  surface,  if  the  vein  is  deep-seated,  but 
at  a  more  obtuse  angle  if  the  vessel  is  more  superficial ;  the 
mere  straightening  of  the  thumb  and  fore-finger  serves  to 
force  the  point  of  the  instrument  through  the  integuments 
and  the  anterior  wall  of  the  vein,  when,  so  soon  as  the  escape 
of  blood  and  the  cessation  of  resistance  to  the  entrance  of 
the  blade  make  the  surgeon  aware  that  the  point  is  within 
the  cavity  of  the  vessel,  he  depresses  the  handle  of  the  instru- 
ment, and  at  the  same  time  pushes  it  a  little  forwards  by  his 
thumb  and  fore-finger,  until  the  incision  has  been  made  suf- 
ficiently long,  when  the  blade  is  withdrawn  ;  or  it  is  perhaps 
safer  to  force  the  blade  to  cut  its  way  out  of  the  vein,  so  soon 
as  the  latter  has  been  entered,  by  depressing  the  handle 
more  and  more,  thus  bringing  the  cutting  edge  in  contact 
with  the  anterior  wall  of  the  vessel  and  with  the  integuments, 
successively :  in  this  way  there  can  be  but  little  danger  of 
penetrating  the  posterior  coats  of  the  vein  with  the  point  of  | 
the  lancet.  The  incision  should  generally  be  somewhat  oblique 
with  regard  to  the  axis  of  the  vein,  especially  if  the  vessel 
be  of  small  calibre,  as  otherwise  the  blood  will  escape  more 
slowly. 

If  the  spring-lancet  is  used,  it  should  be  held  more  or  less 


FOR    GENERAL    BLEEDING.  249 

obliquely  to  the  course  of  the  vein,  according  as  the  vessel  is 
of  small  or  large  calibre :  when  the  vein  to  be  opened  is  su- 
perficial, the  point  of  the  blade  should  be  held  a  little  above 
the  skin,  so  that  it  shall  simply  enter  the  vessel,  and  not  pierce 
entirely  through  it ;  if,  on  the  contrary,  the  vein  is  more  deeply 
seated,  the  point  of  the  fleam  should  rest  upon  the  surface. 
In  bleeding  from  a  vein  which  is  directly  over  the  artery,  the 
incision  should  be  made  upon  the  side  of  the  vessel,  instead  of 
its  anterior  face,  as  being  less  liable  to  penetrate  to  the  ar- 
tery itself. 

If,  after  the  incision  has  been  made,  the  blood  does  not  flow 
freely,  the  patient  may  be  directed  to  grasp  something  in  his 
hand,  as  a  cane,  closing  and  relaxing  his  fingers  upon  it  al- 
ternately, thus  compressing,  by  the  contraction  of  the  mus- 
cles, the  deep  veins,  and  forcing  the  blood  into  the  more  su- 
perficial channels;  the  current  through  the  vein  is  sometimes 
impeded  by  a  constriction  of  the  artery,  arising  from  the  too 
tight  application  of  the  bandage,  which  should  of  course  be 
loosened :  again,  it  may  occasionally  happen  that  a  shred  of 
adipose  tissue  may  obtrude  itself  across  the  incision,  and  thus 
obstruct  the  escape  of  the  blood ;  the  remedy  for  this  difficulty 
will  at  once  suggest  itself  to  the  operator.  Syncope,  accom- 
panied by  cessation  of  the  flow,  is  at  times  produced  by  the 
dread  of  the  operation  which  some  persons  experience,  or  by 
the  sensation  of  the  incision  itself,  or  by  the  sight  of  the  blood, 
in  very  sensitive  patients ;  in  such  instances,  smelling-salts 
should  be  applied  to  the  nostrils,  cold  water  be  dashed  upon 
the  face,  and  the  individual  be  placed  in  the  recumbent  posi- 
tion, until  the  faintness  shall  have  passed  off',  when  the  blood 
will  flow  again,  generally. 

It  is  of  little  consequence  what  kind  of  vessel  is  employed 
to  receive  the  blood  as  it  escapes  from  the  vein  ;  a  common 
bowl  answers  the  purpose  as  well  as  any  other:  however,  if  it 
be  desirable  to  fix  precisely  the  amount  to  be  abstracted,  the 
'*  bleeding-cup"  proper  should  be  used, — a  vessel  having  lines 
upon  its  inner  side  graduated  to  show  the  number  of  fluid- 
ounces  which  it  may  contain  :  such  bowls  may  be  had  of  most 
of  the  druggists. 

After  the  required  amount  of  blood  has  been  drawn,  the 
bandage  should  be  removed  from  the  arm  ;  the  edges  of  the  in- 
cision approximated  by  the  thumb  and  forefinger  of  the  sur- 


250  ON    THE    OPERATIONS 

geon's  left  hand ;  the  surface  cleansed ;  the  compress  placed 
upon  the  wound,  and  retained  in  this  position  by  the  crossed 
bandage,  as  shown  in  figure  18.  In  applying  the  bandage, 
care  should  be  had  that  it  does  not  compress  the  arm  above 
the  opening  in  the  vein  more  than  below  this  point,  otherwise 
the  blood  may  again  flow  from  the  incision.  After  the  lapse 
of  twenty-four  hours,  during  which  time  the  patient  should 
keep  the  elbow  flexed,  and  avoid  using  the  arm, — the  bandage 
may  be  removed,  as  in  most  cases  the  orifice  will  have  become 
sufficiently  closed  to  prevent  the  escape  of  the  blood. 

If  it  be  probable  that  it  will  be  expedient  to  repeat  the 
bleeding  in  the  course  of  twenty-four  hours,  the  necessity  of 
opening  another  vein  may  be  avoided  by  anointing  the  com- 
press with  fresh  lard,  so  that  the  orifice  made  in  the  vein  will 
close  less  speedily  than  when  a  dry  compress  is  applied.  It 
is  requisite  merely  to  remove  the  bandage  and  encircle  the 
arm,  just  above  the  elbow,  with  a  band,  as  in  the  first  bleed- 
ing :  if  the  blood  does  not  escape,  on  the  vein  becoming  tur- 
gid, the  hand  should  be  passed  upwards  along  the  vessel,  when 
the  fluid  will  generally  burst  through  the  imperfectly  closed 
incision ;  if  it  do  not,  a  fine  probe  may  be  used  to  re-open  the 
wound. 

2.  Bleeding  from  the  hand. 

OPERATION. — Compress  the  fore-arm  by  a  circular  bandage 
applied  just  above  the  wrist,  in  order  to  render  turgid  the 
veins  upon  the  back  of  the  hand,  and  make  an  incision  with 
a  thumb-lancet  into  the  largest  of  these  vessels,  in  the  same 
way  as  has  been  directed  above  with  respect  to  the  veins  at 
the  bend  of  the  arm.  The  cephalic  vein,  formed  by  roots  com- 
ing from  about  the  thumb  and  fore-finger,  and  the  vena  salva- 
tella,  from  the  other  fingers,  are  the  largest  trunks.  Care  is 
necessary  that  the  incision  be  not  made  so  deep  as  to  perfo- 
rate the  vein  and  wound  the  subjacent  tendons. 

The  wound,  after  the  bleeding,  should  be  covered  as  in  the 
last-described  operation. 

8.  Bleeding  from  the  ankle. 

OPERATION. — Plunge  the  foot  in  a  basin  of  warm  water, 
and  allow  it  to  remain  until  the  veins  running  along  the  ankle 
ihall  have  become  swollen ;  then  remove  the  foot  from  the 
water,  dry  it,  pass  a  circular  bandage  around  the  leg  just 
above  the  malleoli,  and  open  the  internal  saphena  vein  near 


FOR    GENERAL    BLEEDING.  251 

the  inner  ankle,  the  vessel  being  fixed  by  the  thumb  of  the 
left  hand,  placed  just  below  the  point  of  the  intended  incision. 
The  opening  should  be  oblique,  and  rather  longer  than  is  re- 
quired for  the  veins  of  the  fore-arm,  so  that  the  blood  may 
have  every  facility  for  its  free  escape.  After  the  incision,  if 
the  current  do  not  flow  readily,  the  foot  should  be  again  placed 
in  the  water,  in  which  case  the  amount  drawn  must  be  judged 
of  by  the  discoloration  of  the  water,  or  by  the  effect  produced 
upon  the  patient. 

The  operator  should  be  careful  to  regulate  the  force  with 
which  he  makes  the  incision  according  to  the  volume  of  the 
vein ;  otherwise,  by  penetrating  too  deeply,  he  incurs  the  lia- 
bility of  breaking  the  point  of  his  lancet  against  the  bone. 
The  thumb-lancet  should  be  used.  The  external  saphena  vein 
is  sometimes  opened  at  the  outer  ankle,  but  it  is  rarely  so 
large  as  the  other.  The  operation  is  performed  as  on  the  in- 
ternal saphena. 

The  requisite  amount  of  blood  having  been  removed  from 
the  vessel,  a  small  compress  should  be  placed  upon  the  inci- 
sion, the  surface  cleansed,  and  a  figure-8  bandage  applied  to 
retain  the  compress,  circling  around  the  leg  and  the  foot,  above 
and  below  the  ankles,  leaving  the  heel  exposed,  and  crossing 
upon  the  instep. 

4.  Bleeding  from  the  external  jugular. 

This  operation  is  rarely  performed,  partly  in  consequence 
of  the  more  or  less  danger  attending  it,  but  chiefly  because 
the  required  amount  of  blood  can  generally  be  taken  from  a 
vein  at  the  elbow.  It  is  sometimes  advisable,  however,  to 
practise  this  operation ;  as,  for  instance,  in  convulsions  occur- 
ring in  young  children,  in  whom  there  is  frequently  much  diffi- 
culty in  bleeding  from  the  arm;  also  in  apoplectic  seizures. 

When  it  is  determined  to  open  the  external  jugular,  the  in- 
cision is  usually  made  between  the  lower  third  of  the  vein  and 
a  point  two  inches  above  the  clavicle.  Below  this  point,  there 
may  be  danger  that  the  air  will  enter  through  the  orifice  to 
the  heart,  thus  causing  almost  instant  death.  Above  its  lower 
third,  the  vein  is  so  surrounded  by  nervous  filaments  that  the 
incision  of  the  former  would,  very  probably,  implicate"  the 
latter. 

OPERATION. — The  patient  is  placed  in  a  sitting,  or  in  the 
recumbent,  posture ;  a  thick  compress  should  be  laid  upon  the 


252 


ON    THE    OPERATIONS 


vein  in  the  supra-clavicular  fossa,  and  retained  in  this  position 
by  a  strip  of  muslin,  or  a  cravat,  which  crosses  the  chest  ob- 
liquely from  this  point  to  the  axilla  of  the  opposite  side,  where 
its  tails  are  united,  as  in  the  accompanying  drawing  (fig.  124.) 


FIG.  124. 


In  opening  the  vein,  the  surgeon  places  the  thumb  of  his  left 
hand  upon  the  compress,  and  his  forefinger  upon  the  swollen 
vein,  just  above  the  point  selected  for  the  incision,  and  opens 
the  vessel  pretty  freely  in  a  line  obliquely  upwards  and  out- 
wards, crossing  the  fibres  of  the  platysma-myoid,  so  that  the 
lips  of  the  wound  may  be  well  separated.  A  tea-cup,  or  a 
small  bleeding-bowl,  should  be  held  against  the  skin  at  the 
lower  edge  of  the  opening  in  the  vein,  to  receive  the  blood  as 


FOR    GENERAL    BLEEDING.  253 

it  escapes :  or  if  the  current  do  not  jet  from  the  orifice,  a  card 
should  be  bent  to  the  form  of  a  gutter,  or  trough,  to  convey 
the  fluid  into  the  cup.  The  compression  should  not  be  inter- 
mitted until  the  operation  is  completed,  and  the  opening  in 
the  vein  closed  by  another  compress  placed  upon  the  wound : 
this  precaution  is  intended  to  prevent  the  ingress  of  air.  The 
compress  may  be  retained  in  place  by  short  strips  of  adhesive 
plaster  laid  across  it,  or  by  the  circular  bandage  of  the  neck, 
described  under  the  head  of  regional  bandages. 

The  escape  of  the  blood  may  be  facilitated,  if  it  do  not 
flow  readily,  by  directing  the  patient  to  move  the  lower  jaw, 
as  in  masticating.  After  the  operation,  difficulty  is  occa- 
sionally experienced  in  arresting  the  flow ;  under  such  cir- 
cumstances the  recumbent  posture  should  be  maintained,  all 
compression  from  clothes  carefully  removed,  and  the  patient 
be  directed  to  breathe  freely  and  fully.  M.  Magistel  closes 
the  wound,  in  such  cases,  with  a  fine  suture. 


ACCIDENTS    ATTENDING    PHLEBOTOMY. 

Fortunately  these  are  rare,  when  the  frequency  of  the 
operation  is  considered,  and  those  which  occur  most  frequently 
are  so  slight  in  themselves  and  in  their  consequences,  as 
hardly  to  merit  the  appellation  of  accidents ;  such  are  the 
formation  of  what  is  termed  a  thrombus,  and  syncope  partial 
or  complete.  The  proper  remedies  for  the  latter  have  been 
mentioned,  in  treating  of  bleeding  from  the  arm.  A  thrombus 
is  a  tumour,  or  swelling,  generally  of  small  size,  produced  by 
the  infiltration  of  blood  into  the  cellular  tissue  surrounding 
the  vein.  It  is  owing,  in  most  cases,  to  the  external  incision 
not  corresponding  exactly  in  situation  with  the  opening  in  the 
vein,  the  correspondence  having  become  destroyed  by  some 
movement  of  the  arm,  or  by  a  want  of  attention  on  the  part 
of  the  operator,  while  making  the  incision,  to  have  the  skin 
tense  and  smooth ;  any  cause  which  will  obstruct  the  ready 
escape  of  the  blood  from  the  vein  to  the  external  surface  may 
develope  a  thrombus.  Generally  it  is  a  matter  of  little  con 
sequence,  giving  rise  only  to  some  swelling,  discoloration,  and 
stiffness  at  the  elbow,  which  inconveniences  will  disappear  in 
a  few  days.  Sometimes,  however,  if  the  effusion  is  large,  the 
22 


254  ON   THE    OPERATIONS 

fluid  is  removed  by  suppuration  instead  of  by  absorption,  and 
there  is  danger  that  the  vein  will  become  involved  in  the 
inflammation. 

The  simpler  cases  of  this  incident  to  bleeding  require  very 
slight  treatment ;  the  removal  of  the  effusion  will  be  hastened 
by  keeping  the  arm  at  rest  and  covering  the  affected  part 
with  soap-plaster,  or  a  wash  of  diluted  spirits  of  camphor,  or 
of  some  similar  resolvent.  If  inflammation  and  suppuration 
occur  in  the  tumour,  a  splint  should  be  confined  upon  the 
back  of  the  arm  and  fore-arm,  to  maintain  perfect  repose  of 
the  tissues  about  the  elbow,  and  leeches,  cold  lotions,  irriga- 
tion, or  poultices,  should  be  made  use  of,  according  to  the 
condition  of  the  tumour. 

By  carefully  watching  the  escape  of  the  blood  during  the 
operation,  the  surgeon  may  often  guard  against,  or  arrest,  the 
formation  of  a  thrombus,  by  maintaining  the  parallelism  be- 
tween the  wound  in  the  integuments  and  that  in  the  vein,  or 
by  restoring  this  condition  if  it  has  been  deranged.  If  this 
correspondence  cannot  be  regained,  and  the  tumour  increases 
in  size,  the  external  incision  should  be  enlarged  sufficiently 
to  permit  of  the  blood  reaching  it,  or  another  vein  should  be 
opened. 

WOUND  OF  A  NERVE. — This  accident  may  happen,  and  it 
has  occurred  to  the  most  skilful  operators  in  bleeding,  and  it 
cannot  be  considered  as  a  subject  of  reproach.  It  will  be  re- 
cognised by  some  disturbance  in  the  functions  of  the  part  to 
which  the  nerve  is  distributed.  If  the  wounded  nerve  be  a 
nerve  of  sensation,  pain  will  be  experienced  at  the  seat  of  the 
incision,  or  at  the  terminal  ramifications  of  the  nerve,  a  sen- 
sation of  numbness  or  of  tingling,  or  the  skin  will  be  deprived 
of  sensibility.  If  it  be  a  motor  nerve  which  has  been  impli- 
cated in  the  incision,  the  muscle,  or  muscles,  to  which  it  gives 
power  will  be  more  or  less  paralysed,  or  be  the  seat  of  irregu- 
lar motor  action,  spasmodic  twitches,  tetanic  rigidity,  and  the 
like. 

This  accident  is  a  much  more  serious  one  than  those  already 
considered,  and  should  be  so  regarded.  The  treatment  con- 
sists in  the  application  of  antiphlogistic  or  anodyne  remedies 
to  the  surface,  according  to  the  symptoms ;  in  securing  the 
limb  to  a  splint  in  a  semiflexed  position,  and  in  the  adminis- 
tration of  opiates  internally.  The  limb  should  be  kept  in  a 


FOR    GENERAL    BLEEDING.  255 

state  of  perfect  rest  on  a  splint,  for  two  or  three  weeks,  or  so 
long  as  there  is  any  probability  of  the  reunion  of  the  cut 
extremities  of  the  nerve,  experiments  and  observations  having 
shown  that  restoration  of  the  functions  of  nerves  simply 
divided  does  take  place.  (Carpenter's  Human  Physiol. ; 
Muller's  Physiol.  vol.  i.  p.  457,  &c.) 

WOUND  OF  AN  ARTERY. — The  brachial  artery  is  the  one 
most  liable  to  be  wounded  in  phlebotomy,  and  its  accidental 
puncture  may  be  taken  as  a  type  of  similar  injuries  of  other 
arteries.  The  signs  usually  mentioned  as  indicative  of  this 
accident  are,  the  flowing  of  the  blood  in  jets  from  the  external 
opening,  and  the  bright-red  hue  of  the  fluid.  These  appear- 
ances, however,  are  fallacious,  for  venous  blood  is  not  always 
of  a  dark  blue  colour ;  in  fact,  in  many  persons  and  in  some 
diseases,  its  colour  approaches  very  nearly  to  the  hue  of  arte- 
rial blood ;  and  if  the  vein  which  has  been  opened  is  seated 
immediately  upon  the  brachial  artery,  the  pulsations  of  this 
vessel  will  often  agitate  the  vein,  and  communicate  a  jetting 
motion  to  the  current  as  it  escapes  from  the  latter.  The 
occurrence  of  the  accident  may  be  recognised  pretty  surely, 
by  observing  whether  the  blood  continues  to  flow  from  the 
external  wound,  when  the  vein  is  compressed  at  the  lower 
edge  of  the  incision ;  if  such  is  the  case,  the  artery  has  pro- 
bably been  opened,  the  only  circumstance  likely  to  mislead 
the  observer  arising  from  the  communication  of  another  vein 
with  the  one  in  which  the  aperture  has  been  made,  opposite 
the  orifice  ;  this  must  be  a  very  unusual  incident.  Additional 
knowledge  may  be  acquired  as  to  the  non-existence  of  injury 
to  the  artery,  by  compressing  this  vessel  at  some  point  above 
the  wound,  when,  if  the  colour  of  the  blood  remain  as  before, 
the  inference  from  this  fact,  conjoined  with  the  cessation  of 
the  flow  when  the  vein  is  compressed  below  the  orifice,  while 
the  artery  still  pulsates  at  the  wrist,  is,  that  only  the  vein  has 
been  opened.  Again,  if  the  external  wound  be  closed  with 
sufficient  force  to  compress  the  vein  merely  without  obliter- 
ating the  artery,  a  gradually  increasing  tumour  will  be  devel- 
oped in  the  tissues,  if  the  artery  has  been  punctured.  The 
existence  of  the  injury  having  been  ascertained,  there  can 
still  be  no  impropriety  in  permitting  the  blood  to  escape  until 
the  amount  originally  intended  to  be  drawn  has  been  removed. 
Then  the  surgeon  must  determine  whether  it  is  better,  in  the 


256  ON    THE    OPERATIONS 

particular  instance,  to  endeavour  to  remedy  the  accident  by 
the  long-continued  employment  of  a  compress  and  bandage, 
or  to  obliterate  the  artery  at  once  by  the  application  of  a 
ligature,  or  ligatures.  M.  Velpeau  recommends  that  the  first 
method  be  tried  for  a  week  or  two,  unless  some  serious 
appearance  present  itself.  (Yelpeau,  op.  cit.  p.  312.)  This 
course  having  been  determined  upon,  a  graduated  compress 
should  be  formed,  of  a  pyramidal  shape,  and  applied  with  its 
apex  upon  the  wound,  a  figure-8  bandage  being  made  to  retain 
it  in  place  with  a  degree  of  compressive  force  considerably 
greater  than  would  be  sufficient  to  obliterate  the  vein  merely, 
so  that  the  pulsation  at  the  wrist  shall  be  arrested  (fig.  125) ; 
the  limb,  from  the  fingers  to  the  axilla,  should  be  enveloped 
carefully  in  a  roller-bandage,  and  maintained  in  a  state  of 
perfect  rest  upon  a  splint,  in  the  straight  position  ;  the  patient 
should  remain  in  bed,  or  his  arm  should  be  supported  in  a 
sling.  If,  after  compression  has  been  employed,  the  forma- 
tion of  an  aneurism  be  detected,  the  treatment  necessary  for 


PLAN  OF  A  GRADUATED  COMPRESS.  —  a,  the  artery  wounded ;  b,  b,  the 
graduated  compress  arranged  so  that  the  apex  of  the  cone  is  in  immediate 
contact  with  the  arterial  orifice,  while  its  mass  occupies  the  general  wound, 
and  projects  somewhat  above  the  integumental  level. 

this  affection  must  be  adopted ;  for  this,  and  for  the  best 
method  of  obliterating  the  artery  by  ligature,  if  the  treatment 
by  compression  be  rejected  at  first,  the  reader  is  referred  to 
treatises  on  practical  surgery. 

WOUNDING  or  THE  TENDON  OF  THE  BICEPS,  OR  OF  OTHER 
MUSCLES. — It  happens  occasionally  that  one  of  the  tendons 
is  pricked  by  the  point  of  the  lancet,  when  it  is  seated  beneath 
the  vein  which  has  been  opened ;  or  the  operator  may  have 
mistaken  the  tendon  for  the  vein,  and  plunged  his  lancet 
therein.  Some  degree  of  pain  and  difficulty  in  using  the 


FOR    GENERAL    BLEEDING.  257 

muscle  are  generally  experienced,  after  such  an  accident,  but 
the  symptoms  are  rarely  of  a  violent  character.  The  treat- 
ment" consists  in  keeping  the  limb  at  rest  upon  a  splint,  the 
muscle  being  relaxed,  and  in  the  application  of  anodyne  and 
emollient  remedies.  In  irritable  patients,  it  may  be  advisable 
to  abstract  blood  from  the  part,  by  leeches,  and  to  administer 
opiates. 

ARTERIOTOMY. 

The  temporal  artery  is  the  only  one  upon  which  this  ope- 
ration is  now  practised,  and  very  rarely  is  it  considered 
advisable,  even  on  this  vessel.  The  artery  is  superficial,  is 
favourably  situated  for  compression  after  the  operation,  and 
is  generally  large  enough  to  allow  of  the  abstraction  of  a 
sufficient  amount  of  blood.  Although  the  incision  of  the 
vessel  is  one  of  the  simplest  of  operations,  it  is  sometimes 
followed  by  the  development  of  an  aneurism. 

A  strong  lancet,  or  a  bistoury, — a  graduated  compress, — a 
narrow  roller,  two  or  three  yards  long,  —  warm  water  and  a 
towel,  are  all  that  are  usually  needed  for  the  operation. 

The  trunk  of  the  temporal  artery  itself,  or  its  anterior 
branch,  may  be  opened ;  if  the  former,  the  mode  recom- 
mended by  M.  Magistel  may  be  resorted  to,  as  follows : — 
The  position  of  the  trunk  is  ascertained  at  the  point  where  it 
is  most  superficial,  and  where  its  pulsation  is  most  forcible, 
and  there  marked  with  ink  in  the  direction  of  the  intended 
incision :  this  point  will  be  found  a  little  in  advance  of  the 
ear,  and  above  the  zygomatic  arch.  The  patient  may  sit  up, 
or  assume  the  recumbent  position,  his  head  resting  upon  a 
pillow  on  the  opposite  temple ;  the  surgeon  steadies  the 
artery  by  one  finger  placed  upon  the  surface,  on  the  outside 
of  the  vessel,  and  about  a  quarter  of  an  inch  above  the  site 
of  the  intended  incision  ;  the  bistoury  is  held  as  the  lancet  in 
phlebotomy,  and  entered  through  the  integuments  on  the 
inner  side  of  the  artery,  cutting  its  way  obliquely  through 
the  vessel  and  the  integuments  of  the  opposite  side.  The 
blood  is  received  directly  in  a  cup,  or  it  is  guided  to  the 
latter  through  a  little  gutter  of  paper,  placed  against  the  sur- 
face beneath  the  opening  :  a  plug  of  cotton  should  be  inserted 
into  the  chamber  of  the  external  ear,  to  prevent  the  blood 
22* 


258  ON    TOPICAL    BLEEDING. 

from  entering  it.  When  the  proper  amount  has  been  drawn, 
the  flow  is  generally  easily  arrested  by  placing  a  small  com- 
press of  folded  linen  upon  the  orifice,  (its  lips  having  been 
placed  in  apposition,)  and  securing  it  thus  by  a  few  circular 
turns  of  a  roller.  If  this  be  insufficient  to  stop  the  bleeding, 
a  fine  suture  may  be  passed  through  the  edges  of  the  wound. 
(Malgaigne,  Med.  Ope'rat.) 

If  the  blood  do  not  flow  freely,  the  patient,  if  he  be  coib- 
scious,  should  be  requested  to  move  his  jaw,  as  in  mastica- 
tion, or  a  sponge  filled  with  warm  water  may  be  laid  upon  the 
vessel. 

M.  Velpeau  advises  that  one  of  the  branches  of  the  artery 
be  selected  for  the  operation,  particularly  the  anterior 
branch  in  its  course  towards  the  forehead,  as  it  is  very  super- 
ficial, and  reposes  so  nearly  upon  the  bone,  that  a  firm  com- 
pression may  be  made  upon  it.  The  mode  of  performing  the 
operation  is  the  same  as  for  the  trunk  itself:  the  lancet  may 
be  used  as  in  opening  a  vein,  or  a  bistoury  may  be  employed, 
and  the  integuments  and  vessel  divided,  from  the  former 
towards  the  latter,  and  from  the  outer  side  of  the  artery 
towards  the  operator.  See  fig.  124. 


SECTION  II. 
ON    TOPICAL    BLEEDING. 

1.  On  the  application  of  the  cupping  apparatus. 

In  professional  language,  "a  cup'  is  a  small,  bell-shaped 
vessel,  made  of  glass,  or  thin  metal,  intended  for  application 
to  the  surface  of  the  body,  with  the  view  either  of  removing 
a  certain  amount  of  blood  from  the  minute  veins  and  arteries 
which  have  been  previously  incised,  or  of  merely  producing  a 
congestion  of  the  surface,  or  a  certain  degree  of  ecchymosis. 
The  first  is  termed  "wet-cupping,"  or  simply  "cupping,"  the 
latter  "  dry-cupping." 

Dry  cupping  is  effected  by  merely  acting  upon  the  air 
wiihin  the  cup,  so  that  the  integuments,  on  the  surface  of 
which  it  is  placed,  shall  be  forced,  by  the  pressure  of  the 
atmosphere  without,  into  the  partial  vacuum  formed  within 
the  vessel.  This  vacuum  may  be  produced  in  several  differ- 


ON    TOPICAL    BLEEDING.  259 

ent  ways,  either  by  means  of  heat  so  applied  as  to  rarefy  the 
air  within  the  enclosure,  or  by  the  direct  abstraction  of  a  cer- 
tain portion  of  it  through  the  aid  of  a  pump.  The  latter  is 
the  most  convenient  and  the  most  eligible  mode.  The  pump 
is  made  to  fit  upon  the  summit  of  the  cup,  which  is  perforated 
with  a  small  hole  covered  with  a  thin  valve  of  oil-silk,  or 
of  gum-elastic,  to  exclude  the  entrance  of  air  from  without ; 
while,  by  the  action  of  the  pump,  a  very  considerable  ex- 
haustion can  be  effected  within  the  cup.  The  cup  is  best 
made  of  glass,  so  that  the  degree  of  turgescence  of  the  inte- 
guments can  be  seen ;  when  this  is  deemed  sufficient,  the 
glass  is  easily  detached  from  the  surface  by  slightly  raising 
the  valve  by  means  of  a  pin  inserted  beneath  it,  when  the 
pressure  of  the  atmosphere  within  and  without  the  cup  will 
become  equalized. 

If  this  complete  cupping  apparatus  be  not  at  command,  the 
operation  may  be  sufficiently  well  performed  by  using  a  com- 
mon wine-glass,  or  tumbler.  The  vessel  may  be  immersed  in 
Lot  water,  in  order  to  heat  its  surface,  and  then,  before  it 
becomes  cooled,  applied  upon  the  skin ;  thus  the  air  which  it 
contains  becomes  rarefied  by  the  heat  of  the  material  of 
which  the  cupping  vessel  is  composed,  and  retreats  before  the 
ascent  of  the  integuments,  which  are  pressed  upwards  by  the 
weight  of  the  air  surrounding  the  cup  ;  or  the  inner  surface  of 
the  cup  may  be  moistened  with  spirits  of  wine,  which  should 
then  be  inflamed,  and  while  the  vessel  is  yet  warm,  it  should 
be  placed  upon  the  skin ;  or,  finally,  small  pellets  of  cotton,- 
or  strips  of  paper,  may  be  moistened  with  the  same  fluid,  then 
lighted  and  introduced  into  the  cup,  which  is  used  as  above. 
The  vessel  may  be  loosened  from  the  surface  after  a  proper 
time,  by  pressing  upon  the  integuments  at  its  edge,  so  that 
the  air  may  rush  into  the  cavity. 

Dry  cupping  will  be  found  of  great  benefit  in  the  relief  of 
internal  congestions,  when  it  is  not  expedient  to  abstract 
blood.  It  seems  not  to  produce  its  good  effect  by  revulsion 
merely,  or  by  the  external  irritation  which  it  causes,  but  also 
by  rendering  the  vessels  on  the  surface  turgid,  producing  a 
true  ecchymosis,  and  thereby  diminishing  temporarily  the 
amount  of  fluid  in  circulation  through  the  vessels. 

Wet  cupping  requires  that,  in  addition  to  the  local  tur- 
gescence which  the  dry  cupping  occasions,  the  surface  thus 


260  ON    TOPICAL    BLEEDING. 

engorged  shall  be  incised,  its  small  vessels  opened,  and  blood 
be  abstracted  therefrom.  To  accomplish  this  object,  the  cup- 
ping apparatus  must  be  used  as  above  described,  and  after 
the  integuments  have  become  sufficiently  full  of  blood,  the 
cup  should  be  removed  and  a  number  of  incisions  made  on 
the  surface,  deep  enough  to  open  the  subcutaneous  vessels ; 
then  the  cup  is  to  be  re-applied,  and  the  air  again  exhausted 
from  it ;  thus  the  blood  will  flow  readily  from  the  openings 
made.  After  a  sufficient  amount  has  been  obtained,  the  cup 
is  removed  and  the  surface  cleansed ;  generally,  no  dressing 
is  called  for,  but  if  there  be  much  smarting,  cold  or  warm 
water,  or  a  piece  of  linen  spread  with  simple  cerate,  may  be 
applied,  as  may  be  most  agreeable  to  the  patient.  In  direct- 
ing the  use  of  cups,  it  is  generally  considered  that  each  one 
will  draw  one  ounce  of  blood ;  this  is  not  strictly  correct,  as 
the  amount  will  vary  very  much,  according  to  the  vascularity 
of  the  part  to  which  the  application  is  made ;  sometimes  a 
single  cup  will  abstract  several  ounces  if  re-applied  to  the 
same  spot,  and  again  but  a  very  small  proportion  of  this 
amount  can  be  taken.  The  flow  of  blood  may  be  encouraged 
by  immersing  the  cup,  before  it  is  placed  upon  the  skin,  in 
warm  water,  and  by  laying  a  sponge  or  towels  dipped  in  warm 
water  upon  the  surface,  while  the  cup  is  acting.  The  depth 
of  the  incision  must  be  regulated  to  suit  the  character  of  the 
surface;  where  the  integuments  are  thick,  containing  much 
adipose  tissue,  the  incisions  must  be  deeper  than  under  oppo- 
site circumstances.  The  proper  instrument  for  making  the 
incisions  in  cupping  is  the  "scarificator," — a  metallic  box  of 
about  the  same  size  as  the  cup,  having  its  interior  surface 
pierced  with  a  number  of  slits,  through  each  of  which  a  lancet- 
blade  is  made  to  protrude  by  means  of  a  spring,  the  frame 
upon  which  the  blades  are  secured  being  elevated  or  depressed, 
so  as  to  regulate  the  depth  of  the  incisions,  by  the  turning  of 
a  screw  arranged  for  the  purpose.  In  the  absence  of  this  sca- 
rificator,  the  necessary  incisions  may  be  made  by  a  scalpel,  or 
a  thumb-lancet ;  they  may  be  parallel  to  each  other,  or  crossed, 
or  have  an  oblique  direction. 

The  operation  of  cupping  is  sometimes  a  painful  one,  par- 
ticularly upon  surfaces  not  very  well  cushioned  by  integu- 
ment, as  on  the  chest  of  thin  persons,  and  also  when  performed 
over  inflamed  cavities,  as  upon  the  abdomen  in  gastritis,  en- 


ON    TOPICAL    BLEEDING.  261 

teritis,  or  peritonitis ;  but  even  in  these  latter  cases,  the  ope- 
ration may  be  effected  with  comparatively  little  pain,  by  first 
applying  a  poultice,  or  a  fomentation,  upon  the  surface ;  thus 
the  sensibility  of  the  part  becomes  lessened.  This  is  a 
matter  of  considerable  consequence,  as  leeches  cannot  always 
be  obtained  in  all  situations ;  and  by  the  simple  precaution 
just  stated,  cups  may  be  very  well  used  instead,  in  numerous 
instances  in  which,  otherwise,  the  advantages  of  local  deple- 
tion must  be  foregone. 

It  is  of  importance  to  bear  in  mind  that  the  benefit  of 
cupping  does  not  consist  in  the  local  abstraction  of  blood 
merely,  but  also  in  the  stimulation  which  it  effects  upon  the 
surface  to  which  the  cups  are  applied,  and  in  the  revulsive 
action  which  is  thereby  occasioned. 

2.  On  the  employment  of  leeches. 

There  are  many  cases  demanding  local  depletion,  in  which, 
from  peculiarity  of  situation,  or  excessive  sensitiveness  of 
the  surface,  cups  cannot  be  employed ;  in  such  instances, 
leeches  may  be  used,  as  also  in  all  other  conditions  requiring 
the  topical  abstraction  of  blood. 

Previous  to  the  application  of  the  leech,  the  surface  on 
which  it  is  to  be  placed  should  be  cleapsed  with  warm  water, 
so  as  to  remove,  as  far  as  possible,  any  matter  which  may 
adhere  to  the  skin,  either  as  the  result  of  medicinal  applica- 
tions, or  as  incident  to  the  natural  or  diseased  processes  going 
on  in  the  part :  if  this  precaution  be  not  taken,  much  diffi- 
culty and  delay  will  be  experienced  in  inducing  the  leech  to 
fasten  upon  the  surface,  and  the  animal  itself  may  be  injured 
or  killed,  by  the  introduction  into  his  system  of  such  noxious 
matter.  If  the  surface  to  be  leeched  be  covered  at  all  thickly 
with  hair,  as  the  pubis,  the  scalp,  &c.,  it  should  be  shaved 
before  the  leech  is  applied  to  it.  When  a  number  of  leeches 
are  to  be  applied  to  a  circumscribed  part,  it  is  often  found 
difficult  to  confine  them  within  a  sufficiently  restricted  range, 
if  they  are  simply  placed  on  the  surface ;  this  may  be  over- 
come by  moistening  the  skin,  at  different  points,  with  blood 
drawn  from  the  tip  of  the  finger,  or  with  sugar  and  water ; 
or  the  leeches,  as  many  as  are  intended  to  be  employed,  may 
be  put  into  a  tumbler,  or  wineglass,  which  should  then  be  in- 
verted upon  the  skin ;  or,  finally,  the  palm  of  the  hand  may 
be  covered  with  a  napkin,  and  the  leeches  placed  upon  tho 


262  ON    TOPICAL    BLEEDING. 

latter,  and  thus  held  against  the  surface  until  they  shall  have 
attached  themselves.  When  blood  is  to  be  taken  from  the 
mucous  membrane  lining  a  canal,  it  is  necessary  to  place  the 
leech  in  a  tube,  which  is  then  to  be  introduced  into  the  canal, 
its  open  extremity  applied  to  the  membrane  at  the  proper 
point,  and  there  retained  until  the  leech  has  fastened  itself 
upon  the  surface.  Thus  if  the  depletion  is  to  be  effected 
from  the  neck  of  the  uterus,  the  neck  of  the  bladder,  or  from 
any  part  of  the  vagina,  in  the  female, — a  speculum  of  polished 
metal,  made  of  a  single  piece,  and  having  the  upper  end  cut 
obliquely,  should  be  introduced  into  this  passage  to  the  proper 
distance,  the  polished  internal  face  of  the  speculum  enabling 
the  operator  to  see  each  point  of  the  vagina ;  the  leeches  are 
now  to  be  placed  in  the  speculum,  and  thrust  up  to  the  affected 
spot  by  means  of  a  quill,  or  a  stick.  For  the  rectum,  a  smaller 
speculum  is  required.  For  the  nostrils,  a  tube  of  glass  slightly 
curved  at  its  upper  extremity,  and  about  a  quarter  of  an  inch 
in  diameter,  gradually  tapering  downwards  towards  the  curve, 
may  be  used;  this  should  be  introduced,  and  the  point  of  the 
curvature  carried  opposite  the  spot  upon  which  the  leech  is  to 
be  attached ;  the  animal  is  then  to  be  placed  in  the  cavity, 
and  pushed  upwards  by  means  of  a  quill,  or  a  pencil ;  as  soon 
as  it  has  fastened  upon  the  membrane,  the  tube  may  be  with- 
drawn, and,  if  necessary,  another  leech  introduced  in  the 
same  way.  A  similar  plan  should  be  adopted  in  the  applica- 
tion of  leeches  to  the  gums,  or  to  the  lining  membrane  of  the 
mouth  at  other  points. 

If,  accidentally,  one  or  more  of  these  animals  should 
escape  beyond  the  reach  of  the  operator,  as  into  the  stomach 
or  rectum,  it  may  be  destroyed  by  injecting  a  solution  of  salt 
into  the  cavity  ;  afterwards  the  leech  will  be  discharged  dead. 

Repletion  causes  the  leech  to  fall  from  the  surface  upon 
which  it  had  fastened;  but  if  it  be  expedient  to  detach  it 
before  it  has  become  filled,  fine  salt  should  be  placed  upon  it ; 
it  should  not  be  violently  pulled  from  its  hold  upon  the  skin, 
lest  a  portion  of  its  mouth  remain  in  the  little  wound  which 
it  has  made,  causing  more  or  less  irritation  and  destroying 
the  animal. 

The  quantity  of  blood  which  a  leech  will  draw  varies  very 
much  with  the  kind  of  leech  used,  and  the  degree  of  vascu- 
larity  of  the  surface.  Six  of  the  ordinary  American  leeches 


ON    TOPICAL    BLEEDING.  263 

are  allowed  for  each  ounce  of  blood  required ;  these  answer 
very  well  for  application  to  the  external  surface,  in  situations 
possessing  an  average  condition  of  the  circulation,  and  offer- 
ing space  sufficient  to  allow  of  the  application  of  the  requi- 
site number ;  their  bite  is  less  irritating  and  less  deep  than 
that  of  the  European  leech,  and  hence  they  should  always  be 
employed  upon  children,  and  upon  others  whose  skin  is  prone 
to  a  morbid  degree  of  inflammation  or  soreness,  from  slight 
causes.  An  ounce  of  blood  is  generally  allotted,  as  the 
capacity  of  two  or  three  Swedish,  or  Spanish,  leeches.  These 
are  used  when  the  part  to  be  depleted  is  endowed  with  little 
vascularity,  and  upon  internal  surfaces  of  which  the  secre- 
tions are  naturally,  or  from  disease,  more  or  less  acrid  or 
offensive  to  the  animal,  as  the  mucous  membrane  of  the  vagina, 
that  covering  the  neck  of  the  uterus,  the  rectum,  the  gums ; 
and  it  is  advisable  always,  before  applying  the  leech  to  such 
parts,  to  wash  them  with  warm  water. 

After  the  animal  has  fallen  off,  the  blood  continues  to  flow 
from  the  wound,  but  this  ceases  in  the  course  of  a  few  minutes, 
if  the  bite  be  left  exposed  to  the  air,  unless  a  small  arterial 
branch  of  notable  size  has  been  opened.  If  a  sufficient  de- 
pletion has  been  had,  and  the  bleeding  does  not  cease  of 
itself,  cold  water  should  be  laid  upon  the  surface,  or  dry  lint ; 
and  if  anything  more  effectual  is  necessary,  pressure  with  the 
finger,  a  little  fine  lint  intervening  between  its  point  and  the 
leech-bite,  may  be  made  upon  the  latter  for  a  few  minutes, 
and  then  the  finger  gently  withdrawn,  leaving  the  lint  behind  ; 
this  will  generally  be  sufficient  to  arrest  the  bleeding ;  but  if 
this  fail,  a  fine  point  of  lunar-caustic  should  be  thrust  into 
each  bleeding  wound,  and  quickly  removed ;  finally,  it  is  re- 
commended, in  obstinate  cases  of  such  hemorrhage,  to  pass  a 
fine  needle  transversely  through  the  lips  of  the  wound,  and 
to  lay  upon  it  a  twisted  suture ;  this,  however,  must  be  very 
seldom  required. 

If  it  be  deemed  expedient  to  encourage  the  flowing  of  the 
blood,  warm  water  should  be  laid  upon  the  part,  or  a  warm 
poultice. 

Th£  preservation  of  the  leech  is  a  matter  of  great  import- 
ance. To  insure  this  object,  the  habits  of  the  animal  should 
be  ascertained,  in  order  that  it  may  be  placed  in  circumstan- 
ces in  which  these  habits  and  instincts  may  still  be  indulged. 


264  ON    TOPICAL    BLEEDING. 

It  should  be  kept  in  some  suitable  vessel,  —  an  ordinary  tub 
will  answer, — containing  water,  and  pieces  of  turf,  or,  which 
is  still  better,  of  peat,  into  which  the  animal  may  insinuate 
itself,  and,  by  the  friction  of  its  surface  against  the  interlaced 
roots  of  which  the  peat  is  composed,  cleanse  itself  of  the 
slimy  secretion  which  covers  it,  and  which,  if  permitted  to 
remain  long  upon  the  exterior,  prevents  the  proper  perform- 
ance of  certain  functions  on  which  the  health  of  the  leech 
depends.  The  water  moreover  should  be  changed  as  often  as 
once  every  week,  and  the  leeches  should  be  washed,  unless 
they  have  the  means,  as  above  described,  of  performing  this 
office  for  themselves.  The  animal  obtains  its  supply  of  oxygen 
from  the  air  entangled  in  the  water,  and  not  by  rising  to  the 
surface  to  breathe. 

In  this  way  leeches  may  be  preserved  for  an  indefinite 
length  of  time,  until  needed  for  application  ;  but  after  they 
have  been  once  employed  in  drawing  blood,  they  never  are  so 
efficacious  again.  If  they  have  been  applied  to  abstract  blood 
from  persons  suffering  from  some  malignant  or  contagious 
disease,  they  should  not  be  used  subsequently. 

The  natural  food  of  the  leech  consists  of  smaller  aquatic 
animals  which  it  meets  with  in  its  native  haunts ;  and  the 
admirable  apparatus  with  which  it  is  provided,  and  which 
adapts  it  so  perfectly  to  the  purpose  to  which  it  is  made 
subservient  in  the  treatment  of  disease,  would  seem  to  be 
contrived  for  the  especial  benefit  of  man,  —  to  be,  in  a  mea- 
sure, an  appendix  to  the  animal,  and  not  called  for  in  the 
operations  of  its  own  economy.  Hence,  although  the  blood 
with  which  it  fills  itself  to  distension,  in  the  gratification  of  its 
voracious  thirst,  does  not  putrefy  in  the  animal's  stomach, 
notwithstanding  the  length  of  time  during  which  it  will  be 
retained  in  this  cavity,  unless  it  be  evacuated  artificially, — in 
most  cases,  the  animal  will  die  unless  the  blood  be  removed 
from  it.  (T.  Rymer  Jones's  Comparative  Anatomy.)  To 
accomplish  this,  it  is  requisite  merely  to  place  some  fine  salt, 
or  salt  water,  upon  the  leech,  which  will  cause  the  animal  to 
eject  the  contents  of  its  stomach  by  the  mouth.  The  author 
is  informed  by  Mr.  Moore,  who  is  one  of  the  best  leechers  in 
this  city,  that  he  effects  the  removal  of  the  blood  by  making 
one  or  two  small  punctures  on  the  back  of  the  leech,  on  each 
Hide  of  the  middle  line ;  the  contents  of  the  stomach  and  of 


ON    TOPICAL    BLEEDING.  265 

the  numerous  sacciform  appendages  to  this  central  cavity  are 
evacuated  through  these  punctures,  which  soon  close  again 
without  having  injured  the  animal  at  all.  Mr.  Moore  prefers 
this  method  to  the  use  of  salt,  which  he  thinks  is  in  some 
measure  hurtful  to  the  leech.  Leeches  which  have  thus  been 
emptied  of  the  blood  that  they  have  drawn,  should  be  placed 
in  a  vessel  containing  water  and  turf,  as  above  mentioned, 
and  kept  distinct  from  others  for  two  or  three  weeks,  after 
which  they  may  again  be  employed. 

Within  a  few  years  past,  "  artificial  leeches,"  as  they  are 
called,  have  been  introduced.  These  are  small  tube-shaped 
cupping-glasses ;  their  diminutive  size  permits  them  to  be 
applied  where  the  ordinary  cupping-glass  could  not  be  placed. 
They  are  not  comparable  to  leeches  as  a  means  of  abstracting 
blood  from  certain  parts;  but  they  may  prove  serviceable 
under  circumstances  when  leeches  cannot  be  procured. 

Simple  scarification  of  the  surface  with  a  lancet  or  scalpel, 
is  sometimes  resorted  to  as  a  means  of  local  depletion.  It 
can  only  be  employed  on  very  vascular  parts,  as  on  the 
tongue,  the  mucous  membrane  lining  the  interior  of  the 
mouth,  and  that  covering  the  fauces  and  the  eyelids. 


23 


CHAPTER  III. 

ON    THE    DIFFERENT    MODES    OF    EFFECTING   CUTANEOUS 
IRRITATION. 

IT  has  long  been  an  established  principle  in  medicine,  that 
•when  a  point  of  irritation  exists  in  any  part  of  the  body,  there 
will  be  a  corresponding  accumulation  at  that  point  of  organic 
energy  and  of  circulating  blood  ;  and  the  physical  and  chemi- 
cal changes  which  accompany  every  manifestation  of  organic 
action  will  be  proportionately  more  rapid  and  complete.  To 
admit  of  this  concentration  of  vitality  upon  a  particular  part 
of  the  body,  the  system  elsewhere  seems  to  suffer,  as  it  were, 
a  transfer  of  some  portion  of  the  vital  energy  allotted  to  it. 
Hence  the  resort  to  counter-irritation,  or  revulsion,  in  the 
treatment  of  disease  :  an  exaltation  of  life  is  artificially  occa- 
sioned in  a  particular  part  of  the  surface,  with  the  view  of 
diminishing  or  annulling  the  same  condition,  as  the  result  of 
disease,  in  another  and  generally  neighbouring  organ.  By 
properly  varying  the  means  resorted  to,  the  kind  and  degree 
of  action  thus  established  may  be  suited  to  the  different  states 
which  it  is  the  object  of  the  surgeon  to  counteract.  These 
means  are  chiefly  rubefacients,  vesicatories,  and  such  as  pro- 
duce suppuration. 


SECTION  I. 
OF    RUBEFACIENTS. 

These  are  applications  which  excite  an  erythematous 
inflammation  of  the  skin,  terminating  in  complete  resolution, 
and  followed  frequently  by  desquamation  of  the  cuticle  upon 
which  they  were  placed.  Their  local  action  is  strictly  counter- 
irritant,  not  combined  with  any  depletory  influence ;  but,  in 
addition  to  this,  they  produce  a  considerable  degree  of  general 

excitement. 

(266) 


OF    KTJBEFACIENTS.  267 

There  are  many  applications  which  produce  this  effect: 
water,  sand  contained  in  a  suitable  vessel,  and  heated  to  a 
temperature  somewhat  above  that  of  the  surface  of  the  body 
(from  100°  to  150°),  will  excite  an  erythema  of  the  skin ; 
the  same  result  follows  the  application  to  the  surface  of  the 
aromatic  oils  and  powders,  of  spirits  of  turpentine,  dilute 
aqua  ammoniae,  the  "  linimentum  cantharidis,"  and  many 
other  substances.  But  the  means  most  commonly  employed 
as  rubefacients  are  sinapisms,  or  poultices  made  of  ground 
mustard-seed.  In  order  to  prepare  the  flour  for  application,  it 
should  be  mixed  with  water,  and  spread  evenly  upon  a  piece 
of  muslin,  having  the  surface  which  is  to  be  placed  next  the 
skin  covered  with  a  piece  of  thin  gauze  or  cambric.  The 
efficacy  and  rapidity  of  action  of  the  sinapism  may  be  in- 
creased, by  adding  vinegar  to  the  flour,  instead  of  using  water, 
and  also  by  incorporating  it  with  a  mixture  of  oil  of  turpen- 
tine and  water.  This  applies  only  to  the  white  mustard-seed 
powder. 

The  length  of  time  during  which  a  sinapism  should  be 
allowed  to  remain  in  contact  with  the  skin  depends,  in  a  mea- 
sure, upon  the  sensitiveness  of  the  surface,  and  the  patient's 
general  sensibility.  In  the  course  of  a  few  minutes  after  the 
application  has  been  made,  a  sensation  of  warmth  is  induced, 
which  becomes  more  and  more  powerful,  so  that  after  the 
lapse  of  twenty  minutes  it  cannot  be  tolerated,  generally,  with 
any  degree  of  comfort.  It  should  now  be  removed,  and  re- 
applied  at  intervals,  upon  the  same  part,  or  upon  other  regions, 
as  may  be  indicated.  If  it  be  suffered  to  vesicate  the  skin,  a 
very  troublesome  sore  often  results,  and  sometimes  gangrene, 
from  excessive  inflammation.  Attention  to  the  duration  of 
the  application  is  particularly  necessary  when  the  patient  is 
unconscious,  or  only  partially  sensible,  as  the  pain  arising 
from  the  action  of  the  mustard,  in  ordinary  circumstances,  is 
not  complained  of  now,  and  great  inflammation  may  be  caused 
before  this  effect  is  suspected.  By  combining  some  other 
kind  of  meal  with  that  of  the  mustard-seed,  a  poultice  may 
be  made,  which  will  excite  erythema  more  slowly,  and  which 
may  be  borne  upon  the  skin  for  a  much  longer  time. 

The  ordinary  "spice  poultice," — made  by  mixing  together 
the  powders  of  several  of  the  aromatics,  as  cinnamon,  cloves, 
red  and  black  pepper,  and  mustard-seed,  together  with  wheat 


268  OF    VESICANTS. 

or  flax-seed  meal,  or  bread-crumbs  softened  in  milk  or  water, 
—  is  an  excellent  and  mild  rubefacient  application.  From  a 
half  teaspoonful  to  a  teaspoonful  of  each  of  the  aromatic 
powders  may  be  combined  with  a  sufficient  quantity  of  one 
of  the  other  substances,  to  make  the  poultice  large  enough  for 
the  surface  to  be  covered. 

The  general  stimulant  or  excitant  action  of  rubefacients 
should  be  borne  in  mind  when  their  application  is  directed, 
as  in  many  cases  this  influence  will  be  sufficient  to  counteract 
their  revulsive  effect. 


SECTION  II. 

OF    VESICANTS. 

These  are  characterized  by  the  effusion  of  serum  beneath 
the  cuticle,  caused  by  the  inflammation  arising  from  their  ap- 
plication. Hence,  in  addition  to  their  derivative  effect  from 
the  diseased  organ,  and  the  general  excitement  which  they 
occasion,  they  act  also  as  depletants :  this  last  peculiarity 
serves  to  counteract  the  injurious  impression  which  would 
otherwise  be  incident  oftentimes  to  their  stimulant  action. 

Vesication  may  be  produced  by  a  variety  of  applications. 
If  a  very  rapid  effect  is  desired,  probably  the  best  mode  is  to 
saturate  a  cloth,  folded  to  the  proper  size,  in  boiling  water, 
and  lay  it  upon  the  surface,  taking  care  that  the  fluid  does 
not  flow  over  a  larger  space  than  was  intended.  A  piece  of 
metal,  raised  to  a  high  temperature  by  being  plunged  in 
boiling  water,  and  then  placed  in  contact  with  the  skin  ; — or, 
according  to  the  recommendation  of  Carlisle,  metal  heated  to 
redness  and  passed  over  the  surface,  a  fold  of  wetted  cloth 
intervening ; — or  a  jet  of  steam  from  the  nose  of  some  con- 
venient vessel ;  —  all  these  are  at  times  resorted  to  for  the 
purpose  of  raising  a  blister  speedily.  But  they  cause  a  degree 
of  inflammation  which  often  eventuates  in  gangrene,  and  are 
always  very  painful  remedial  agents. 

There  are  three  remedies  of  this  class  which  are  simple  in 
their  application  and  very  manageable,  and  with  which, 
probably,  the  surgeon  may  accomplish  all  that  he  can  hope  to 


OF    VESICANTS.  269 

gain  from  the  use  of  vesicating  applications.  These  are  the 
Spanish  fly,  Croton  oil,  and  aqua  ammonise. 

1st.  The  cerate  made  of  Spanish  flies, — "  ceratum  cantha- 
ridis"  of  the  Pharmacopoeia, — is  the  preparation  which  is 
most  used.  It  may  be  spread  on  coarse  brown  paper,  or  on 
soft  leather,  or,  which  is  much  the  most  convenient  and  most  ele- 
gant substance,  upon  a  piece  of  adhesive  plaster,  as  it  is  pre- 
pared on  sheets  of  linen  for  use.  In  covering  either  of  these 
substances  with  the  cerate,  a  margin  should  be  left  all  around 
free  from  the  salve.  If  the  adhesive  plaster  is  used,  it  will 
be  necessary  merely  to  warm  this  margin,  in  order  to  make 
the  vesicating  agent  adhere  to  the  skin  on  which  it  is  placed : 
if  any  other  substance  is  employed  on  which  to  spread  the 
cerate,  strips  of  adhesive  plaster  should  be  used  to  retain  it 
on  the  surface. 

Before  applying  the  vesicatory,  the  skin  should  be  shaved, 
if  there  be  much  hair  upon  it,  and  moistened  with  vinegar, 
in  order  to  increase  the  rapidity  of  action  of  the  flies ;  and 
it  is  also  advisable  to  cover  the  surface  of  the  cerate  with  a 
piece  of  fine  tissue-paper  moistened  with  vinegar,  as  by  this 
means  none  of  the  blistering  matter  will  adhere  to  the  skin 
after  the  removal  of  the  cerate. 

The  length  of  time  during  which  the  application  should  be 
continued  varies  with  the  part  to  which  it  is  confined,  the  age 
of  the  patient,  and  the  state  of  the  general  sensibility  of  the 
individual :  probably  from  two  to  twelve  hours  may  be  as- 
sumed as  the  minimum  and  maximum  duration.  The  scalp 
being  much  more  tardy  in  responding  to  the  action  of  the 
vesicant  than  any  other  part  of  the  body,  the  application 
should  be  retained  longer  upon  it.  It  is  not  necessary  to  the 
formation  of  the  blister  that  serum  should  actually  be  effused 
beneath  the  cuticle  before  the  vesicating  agent  can  be  re- 
moved. If  the  skin  be  rendered  of  a  bright  red  colour  by 
the  action  of  the  flies,  these  may  be  withdrawn,  and  a  piece 
of  linen  covered  with  simple  cerate,  or  a  poultice,  may  be 
laid  upon  it,  and  in  a  short  time  the  cuticle  will  be  raised  by 
the  serum  poured  out  beneath  it :  excepting  in  some  few  cases, 
where  a  very  powerful  impression  is  -demanded,  the  desired 
results  will  be  obtained  from  this  course  as  fully  as  though 
the  vesicatory  had  been  retained  upon  the  part  for  a  inucn 
longer  time ;  and  this  will  be  found  to  be  the  surest  way  of 
23* 


270  OF    VESICANTS. 

preventing  the  occurrence  of  strangury,  one  of  the  most  un- 
pleasant incidents  to  the  use  of  the  Spanish  fly  as  a  blistering 
application.  In  children  this  method  should  always  be  pur- 
sued, the  cerate  being  kept  upon  the  skin  for  two  or  three 
hours  only,  and  then  it  will  be  rare  that  gangrene,  or  a  very 
high  degree  of  inflammation,  will  endanger  the  life  which  the 
blister  has  perhaps  rescued  from  the  grasp  of  some  formidable 
disease. 

A  very  elegant  and  convenient  preparation  of  cantharides 
is  the  "  cantharidal  collodion,"  as  it  is  called ;  it  is  made  by 
dissolving  gun-cotton  in  an  ethereal  solution  of  cantharides. 
It  is  applied  upon  the  skin  by  means  of  a  camel's-hair  pencil. 
It  is  prompt  in  its  action,  and  the  intensity  of  its  effects  may 
be  pretty  well  regulated  by  the  manner  in  which  it  is  used. 
To  produce  a  very  speedy  and  comparatively  severe  vesica- 
tion,  a  thick  coating  of  the  solution  should  be  applied,  and 
then  covered  with  oiled-silk. 

The  mode  of  dressing  the  blistered  surface  will  depend 
upon  the  effect  whhch  is  desired.  If  it  be  not  important  to 
encourage  a  continued  secretion  or  discharge  from  the  skin, 
the  cuticle  should  be  simply  punctured  with  a  needle,  or  with 
the  point  of  a  thumb-lancet,  and  the  serum  be  suffered  to 
escape,  and  simple  cerate,  or  a  soft  poultice,  be  subsequently 
laid  upon  the  surface ;  in  a  day  or  two  the  irritation  will  have 
subsided.  But  if  a  continuation  of  the  secretion  be  desired, 
the  cuticle  should  be  removed,  having  been  first  cut  around 
its  adherent  edge,  and  the  exposed  surface  of  the  true  skin 
dressed  with  basilicon  cerate,  or  with  savine  cerate.  If,  as  is 
sometimes  the  case,  the  surface  be  very  painful  and  much  in- 
flamed, a  soft  poultice  or  cold  water  will  be  found  the  best 
dressing.  A  sloughy  condition  of  the  part  will  be  best  com- 
bated by  the  application  of  one  of  the  acids  sufficiently  diluted, 
or  creasote,  or  decoction  of  oak-bark,  or  the  solution  of  La- 
barraque,  together  with  the  internal  administration  of  suitable 
tonics.  When  a  blistered  surface  is  tardy  in  healing,  Dr. 
Wood  strongly  recommends  the  application  to  it  of  "the 
cerate  of  subacetate  of  lead  diluted  with  an  equal  weight  of 
simple  cerate." 

Blisters  should  always  be  dressed  with  great  gentleness,  as 
every  one  will  feel  who  has  had  the  misfortune  to  have  been 


OP    VESICANTS.  271 

blistered.  The  tearing  off  the  cuticle,  recommended  by  some, 
is  a  barbarity. 

If  strangury  should  occur,  despite  the  precautions  having 
been  taken  to  prevent  it,  as  above  recommended,  the  patient 
may  drink  pretty  freely  of  flaxseed  tea,  or  if  copious  draughts 
of  liquids  be  objectionable  from  particular  circumstances, 
speedy  relief  will  follow  an  enema  of  a  scruple  of  camphor 
and  twenty  or  thirty  drops  of  laudanum  suspended  in  an 
ounce  or  two  of  water  or  mucilage. 

The  affections  strictly  surgical,  in  which  blistering  by  this 
means  is  most  efficacious,  are,  probably,  periostitis — the  blister 
being  produced  directly  over  the  seat  of  pain ; — fractures  re- 
maining long  ununited — where  the  blister  is  created  in  order 
to  excite  the  vessels  of  the  bone  and  surrounding  soft^parts 
to  an  increased  activity  of  function,  with  the  hope  of  repair- 
ing tbe  injury;  —  erysipelas  —  in  order  to  produce  a  more 
healthy  kind  of  inflammation,  and  thus  to  arrest  the  spread 
of  the  disease ;  —  and  gangrene, —  the  object  being  the  same 
as  in  the  last  affection.  Besides  these,  many  others  may  be 
enumerated  as  being  more  or  less  benefited  by  the  employ- 
ment of  vesicating  remedies,  such  as  caries,  the  various  oph- 
thalmic diseases,  neuralgia,  chronic  articular  inflammations, 
indolent  glandular  and  other  swellings. 

The  general  excitant  effect  of  this  class  is  one  of  the  most 
important  therapeutic  characteristics,  more  marked  in  this 
than  in  the  class  last  considered. 

2.  Croton  oil  —  the  "Oleum  Tiglii"  of  the  Pharmacopoeia 
— is  a  very  mild  and  manageable  counter-irritant.  It  is  more 
adapted  to  chronic  than  to  acute  diseases ;  its  general  stimu- 
lating effect  is  much  less  than  that  of  cantharides,  and  its 
depleting  action  is  comparatively  slight ;  as  a  local  derivative, 
however,  it  exerts  a  decided  impression,  and  this  may  be 
maintained  for  a  long  time  with  less  inconvenience  to  the 
patient  than  by  the  employment  of  the  Spanish  fly. 

The  effect  of  Croton  oil  may  be  obtained  either  by  fric- 
tions, or  by  the  incorporation  of  the  oil  with  some  sort  of 
plaster,  so  that  the  compound  may  be  spread  upon  a  suitable 
substance,  as  leather,  and  worn  upon  the  surface  of  the  body. 
The  first  is  the  method  usually  adopted,  as  vesication  is  occa- 
sioned more  speedily  by  this  than  by  the  plaster.  The  oil 
should  be  diluted  with  one  or  two  parts  of  olive  oil,  or  it  may 


272  OF    VESICANTS. 

be  used  in  its  concentrated  strength,  as  the  skin  upon  which 
it  is  to  be  rubbed  is  more  or  less  tender,  and  as  a  less  or  more 
rapid  action  is  desired.  It  is  common  to  moisten  a  piece  of 
flannel  with  a  few  drops  of  the  oil,  and  to  rub  it  over  the 
surface  until  the  skin  is  decidedly  reddened  and  made  to 
smart ;  this  operation  should  be  repeated  after  an  interval  of 
six  or  eight  hours,  and  a  third  time,  if  necessary ;  two  or 
three  applications  will  generally  be  sufficient,  unless  the  oil 
has  been  much  diluted.  The  vesicles  are  numerous,  some- 
times coalescing,  sometimes  remaining  distinct,  each  one  being 
surrounded  by  a  red  areola,  which,  if  the  vesicles  are  near 
together,  give  the  skin  a  uniform  erythematous  injection. 
The  fluid  is  at  first  clear,  but  soon  becomes  turbid  and  puru- 
loid.  The  irritation  subsides  after  a  few  days,  when  the  ap- 
plication may  be  renewed,  if  indicated. 

If  the  other  method  of  employing  the  oil  be  adopted,  as 
recommended  by  Dr.  Graves,  of  Dublin,  it  may  be  incor- 
porated with  lead-plaster,  in  the  proportion  of  3j.  of  the  oil, 
to  3ij.  or  3iij.  of  the  plaster,  and  spread  upon  kid ;  or  Bur- 
gundy-pitch may  be  substituted  for  the  lead-plaster.  This 
application  will  produce  a  vesicular  eruption  after  it  has  been 
worn  upon  the  surface  for  a  day  or  two. 

In  using  the  Croton  oil,  it  should  be  recollected  that  an 
irritation  of  the  skin  will  be  produced  wherever  the  oil  shall 
happen  to  come  in  contact  with  it,  as  on  the  eyelids  and  face 
from  accidentally  touching  these  parts  with  the  fingers  on 
which  a  little  of  the  oil  has  remained ;  the  consequent  burn- 
ing sensation  and  swelling  are  soon  relieved  by  the  applica- 
tion of  cold  water. 

3.  The  strong  water  of  ammonia  —  "Ammoniae  liquor 
fortior," — may  be  used  when  a  very  rapidly  vesicating  agent 
is  needed.  It  is  applied  by  saturating  with  it  a  piece  of  linen 
folded  to  the  proper  size,  and  laying  it  upon  the  surface  to 
be  blistered,  where  it  should  be  confined  for  two  or  three 
minutes,  care  being  had  that  the  liquid  does  not  flow  upon  the 
surrounding  skin.  -t 

The  blistering  lotion  of  Granville  contains  this  preparation , 
of  ammonia  as  its  active  agent.     He  directs  two  lotions  of 
different  powers  ;  these  are  prepared  thus : 

Strongest  water  of  Ammonia |  and  £ 

Distilled  spirit  of  Rosemary f    "     '• 

Spirit  of  Camphor |    "     | 


SUPPURATIVE    COUNTER-IRRITANTS.        273 

"  The  stronger  lotion  has  been  employed  by  Dr.  Granville 
only  in  cases  of  apoplexy  and  for  the  purpose  of  cauteriza- 
tion. The  first  two  ingredients  are  to  be  gradually  mixed : 
•whereupon  the  mixture  becomes  opalescent  and  gives  out  an 
ethereal  smell.  Before  the  addition  of  the  third  ingredient, 
the  mixture  should  be  rendered  transparent  by  means  of  a 
little  alcohol.  These  lotions  are  stated  to  produce  as  full  a 
vesication  in  a  space  of  time  varying  from  three  to  ten 
minutes,  as  can  be  produced  by  cantharides  in  as  many  hours. 
They  are  applied  by  means  of  folds  of  linen  impregnated 
with  them."  (U.  S.  Dispensatory,  art.  "  Ammon.  Liq.  fort.") 

They  are  used  chiefly  to  relieve  violent  neuralgic  pains. 


SECTION  III. 
OF    SUPPURATIVE    COUNTER-IRRITANTS. 

The  remedies  of  this  class  act  less  promptly  than  rube- 
facients,  or  vesicants,  but  when  the  secretion  of  pus  which  is 
excited  by  them  has  become  established,  they  produce  a  more 
depressing  effect,  inasmuch  as  the  development  and  conti- 
nuance _of  a  suppurative  discharge  involve  a  greater  expen- 
diture of  vital  energy  than  is  called  for  to  produce  an  ery- 
thema, or  a  vesication.  Any  application  which  will  cause  a 
loss  of  substance  of  the  surface  on  which  it  is  made  to  act, 
will  occasion  suppuration  from  the  granulations  by  which  the 
reparation  of  the  tissues  is  accomplished.  Thus  the  strong 
mineral  acids,  the  actual  cautery,  even  a  vesicant  if  it  pro- 
duce a  sufficiently  high  degree  of  inflammation,  will  give  rise 
to  suppuration.  The  substances  most  employed  with  this 
view,  however,  are,  tartar  emetic,  caustic  potassa,  nitrate  of 
silver,  the  seton,  the  issue,  and  the  moxa. 

1.  Tartar  emetic  is  most  frequently  used  in  the  form  of 
the  ointment  made  by  incorporating  the  salt  with  lard,  in 
varying  proportions  according  to  the  strength  required ;  one 
part  of  tartar  emetic  to  two  parts  of  lard  makes  a  powerful 
ointment;  a  more  common  proportion  is  one  of  the  former  to 
four,  or  even  eight,  of  the  latter.  The  strong  ointment  will 
produce  pustulation  in  the  course  of  a  few  hours. 

The  mode  of  using  this  agent  is,  to  rub  a  portion  of  the 


274        STJPPURATIVE   COUNTER-IRRITANTS. 

preparation  upon  the  skin  for  some  minutes,  until  pain  and 
redness  are  excited;  if  a  single  application  be  not  sufficient, 
it  should  he  repeated  at  intervals  of  a  few  hours.  Suppu- 
ration from  the  ulcers  thus  induced  should  be  favoured  by 
dressings  of  some  stimulating  cerate,  or  by  poultices. 

A  saturated  solution  of  tartar  emetic  in  warm  water,  to  be 
rubbed  upon  the  skin  by  the  aid  of  a  piece  of  flannel,  is  a  very 
neat  and  cleanly  method  of  producing  pustular  inflammation. 
Another,  and  a  very  convenient  mode  of  using  this  agent  is, 
to  sprinkle  a  little  of  the  powder  upon  the  surface  of  a  Bur- 
gundy pitch,  or  other  adhesive  plaster,  which  is  then  laid 
upon  the  skin,  and  there  retained  until  pustules  are  deve- 
loped. 

2.  Nitrate  of  silver,  commonly  called  lunar  caustic,  pro- 
duces an  eschar  much  less  deep  than  tartar  emetic,  and  con- 
sequently is  a  less  powerful  application  than  the  other.     It  is 
used  by  moistening  a  stick  of  the  caustic  and  rubbing  it  upon 
the  skin.     As  a  caustic,  it  is  employed  to  cause  a  superficial 
slough  which,  when  it  has  become  detached,  leaves  a  healthy 
granulating  surface,  as  in  the  treatment  of  chancre,  and  old 
ulcers. 

3.  Caustic  potassa,  prepared  in  the  form  of  "  sticks,"  is  a 
much  more  effectual  pustulating  application  than  the  last. 
With  this,  the  tissues  may  be  destroyed  to  almost  any  extent 
and  depth,  and  great  care  is  therefore  necessary  in  making 
use  of  it.     The  best  and  safest  plan  is,  to  lay  upon  the  skin  a 
piece  of  kid,  in  which  a  hole  is  cut  corresponding  in  size  and 
situation  with  the  portion  of  the  skin  on  which  the  caustic  is 
intended  to  act;  then  the  potassa,  slightly  moistened,  is  to  be 
placed,  or  rubbed,  upon  the  skin  thus  exposed,  until  a  suffi- 
ciently thick  eschar  is  produced,  after  which  it  is  advisable  to 
pour  a  little  vinegar  upon  the  part,  in  order  to  render  inactive 
any  portion  of  the  caustic  which  may  still  adhere  to  the  tis- 
sues.    The  separation  of  the  slough,  thus  produced,  should  be 
hastened  by  the  application  of  warm  poultices,  and  the  granu- 
lating surface,  left  exposed  after  the  detachment  of  the  eschar, 
should  be  dressed  with  slightly  stimulating  lotions,  or  cerates, 
to  encourage  the  secretion  of  pus. 

The  "Vienna  paste,"  recommended  by  surgeons  on  the 
continent  of  Europe,  is  made  by  triturating  together,  with  the 
aid  of  a  little  alcohol,  five  parts  of  caustic  potassa  and  six 


SUPPUEATIVE   COUNTER-IRRITANTS.  x   275 

parts  of  quick-lime.  The  compound  is  used  in  the  same  man- 
ner as  the  caustic  potassa  alone,  and  produces  an  eschar  in  a 
few  minutes,  with  less  pain  than  the  other. 

A  paste,  made  by  incorporating  chloride  of  zinc  with  wheat 
flour  and  water,  is  recommended  bj  many  surgeons  as  a  caus- 
tic. M.  Canquoin  prepares  it  of  different  strengths,  accord- 
ing to  the  desired  effect ;  thus,  he  triturates  one  part  of  chlo- 
ride of  zinc  with  two,  three,  four,  or  five  parts  of  flour,  adding 
fifteen  drops  of  water  for  every  ounce  of  the  flour.  The  paste 
thus  formed  is  divided  into  cakes,  varying  in  thickness  from 
one-twelfth  to  one-third  of  an  inch,  and  applied  to  the  part ; 
the  eschar  which  it  causes  may  be  from  one  line  to  an  inch 
and  a  half  deep,  according  to  the  thickness  of  the  portion  of 
caustic,  the  duration  of  its  application,  and  the  character  of 
the  tissue  to  which  it  is  applied.  (U.  S.  Dispens.) 

The  white  oxide  of  arsenic  is  now  rarely  used  as  a  caustic : 
its  application  is  generally  attended  with  great  pain,  and  un- 
pleasant constitutional  effects  have  often  followed  it. 

Iron  heated  to  whiteness  has  been,  in  earlier  times,  much 
resorted  to  as  a  means  of  producing  a  slough  and  subsequent 
suppuration.  It  is  now,  however,  seldom  employed  for  this 
purpose.  When  used  thus,  the  iron  is  called  "the  actual 
cautery"  in  contradistinction  from  the  other  caustics,  to 
which  the  term,  potential  cauteries,  has  been  applied. 

4.  The  moxa,  as  it  is  ordinarily  used,  consists  of  a  cylinder 
of  carded  cotton,  about  an  inch  long  and  from  one  to  two 
inches  in  diameter,  the  whole  wrapped  in  a  piece  of  linen  and 
impregnated  with  a  saturated  solution  of  nitrate  of  potassa, 
or  of  chromate  of  potassa.  To  apply  it,  one  of  the  extremi- 
ties of  the  cylinder  should  be  lighted  in  the  flame  of  a  lamp, 
and  the  other  placed  upon  the  skin,  the  roll  being  beheld  be- 
tween the  blades  of  a  pair  of  dressing-forceps.  The  moxa  is 
maintained  in  a  state  of  ignition  by  blowing  upon  it  with  the 
mouth,  through  a  blow-pipe,  or  with  the  lips  merely,  the  object 
being  to  secure  a  steady  heat.  The  pain  experienced  from 
this  application  becomes  gradually  more  and  more  severe, 
until  the  sensitive  structure  of  the  skin  is  destroyed,  when  it 
ceases.  A  thick  eschar  is  thus  formed,  which,  by  the  con- 
tinued application  of  emollients,  becomes  detached  after  some 
days,  leaving  a  granulating,  suppurating  surface,  requiring 
dressings  suitable  for  such  a  condition. 


276       STTPPURATIVE   COUNTER-IRRITANTS. 

The  rooxa  is  generally  employed  as  a  counter-irritant  in 
diseases  of  the  bones,  as  caries  of  the  spine,  and  is  applied 
near  to  the  seat  of  the  affection, —  not  so  near,  however,  as 
to  involve  the  vessels  and  nerves  in  the  slough  which  is 
formed. 

5.  Issues  are  established  by  the  introduction  into  the  sub: 
cutaneous  tissue  of  some  foreign  body  which  acts  as  an  irri- 
tant, and  thus  perpetuates  a  suppurative  secretion.     The  sub- 
stance generally  used  for  this  purpose  is  made  of  cork,  or  pine 
wood,  or  indeed  of  any  similar  material,  cut  to  about  the  size 
and  shape  of  the  common  garden-pea.     It  is  introduced  into 
the  tissue  either  by  an  incision  made  with  the  knife,  or  it  may 
be  confined  by  means  of  strips  of  adhesive  plaster  upon  the 
granulating  surface,  produced  by  the  action  of  caustic  potassa, 
or  a  vesicating  agent. 

There  is  some  choice  as  to  the  point  at  which  the  issue 
should  be  established  ;  it  may  be  directly  over  the  seat  of  the 
disease,  or,  if  this  be  not  important,  at  some  remote  point. 
The  arm  and  the  back  of  the  neck  are  the  most  convenient 
situations  for  the  formation  of  an  issue ;  in  the  former,  the 
pea  should  be  introduced  in  the  space  between  the  biceps  and 
deltoid  muscles,  near  the  insertion  of  the  latter.  When  the 
neck  is  selected,  any  point  may  be  taken  which  seems  most 
convenient ;  it  should  generally  be  low  down,  so  that  the  pa- 
tient's dress  may  conceal  it  from  view. 

6.  Setons  are  established  by  passing  a  piece  of  tape,  or  a 
skein  of  silk,  or  other  similar  material,  through  a  portion  of 
the  integuments,  and  leaving  it  to  excite  suppuration.     The 
seton  may  be  introduced  by  means  of    the  instrument  con- 
trived by  Boyer  for  the  purpose, — a  blade  shaped  somewhat 
like  that  of  the  thumb-lancet,  but  stronger  and  curved  also, 
and  having  an  eye  cut  in  its  heel,  through  which  the  seton- 
tape,  or  silk,  is  passed  (fig.  126);  —  or  it  maybe  effected  sim- 
ply by  using  a  common  bistoury  and  an  eyed-probe.    In  either 
case,  the  first  step  of  the  operation  is  the  same :  a  fold  of  the 
integuments  is  pinched  up  between  the  thumb  and  fore-finger 
of  the  left  hand,  and  the  blade  of  the  instrument,  previously 
oiled, — be  it  the  seton-needle,  or  the  bistoury, —  is  thrust 
through  its  base ;  if  the  seton-needle  is  used,  it  should  be 
armed  with  the  tape,  or  silk,  and  drawn  through,  its  armature 
following ,  if  the  bistoury  is  employed,  the  probe  is  armed  in 


SUPPUEATIVE     COUNTER-IRRITANTS.         277 
FIG.  126. 


the  same  way,  and  passed  along  the  base  of  the  wound  upon 
the  blade  (fig.  127).     After  the  needle  or  the  probe  has  thus 


FIG.  127. 


cleared  the  incision,  it  is  disconnected  from  the  seton,  and 
the  extremities  of  the  latter  are  tied  together,  forming  a  loop 
which  encloses  a  portion  of  the  integuments ;  a  poultice 
should  be  laid  upon  the  wound,  and  retained  in  place  by  a 
proper  bandage,  for  a  few  days,  until  suppuration  has  become 
established,  when  simple  cerate  may  be  substituted  as  a  dress- 
ing, and  confined  by  adhesive  strips.  The  seton  should  be 
drawn  daily  backwards  and  forwards  across  the  wound,  in 
order  to  stimulate  the  latter  slightly,  and  to  sustain  the  dis- 
charge;  and  once  or  twice  every  week  a  clean  seton  should 
be  introduced,  by  attaching  one  end  of  it  to  one  of  the  ex- 
tremities of  the  tape  already  in  use,  and  drawing  it  within  the 
wound. 

Any  part  of  the  surface  of  the  body  may  be  selected  for 
the  establishment  of  a  seton,  —  the  blood-vessels  and  nerves 
being  avoided,  of  course,  —  but  the  back  of  the  neck,  or  the 
24 


278  OF    ACUPUNCTURE. 

upper  part  of  the  arm,  is  usually  chosen  as  being  the  most 
convenient  part. 

Dr.  Golding  Bird  has  suggested  and  repeatedly  practised 
a  mode  of  inducing  a  continued  purulent  discharge  from  the 
surface,  which  is  free  from  the  objections  generally  enter- 
tained by  patients  against  the  methods  in  common  use.  It 
is  an  elegant  adaptation  of  electricity  to  medical  purposes. 

He  advises  two  small  blisters  to  be  applied  to  the  surface 
at  the  desired  part,  one  a  few  inches  from  the  other ;  when 
the  cuticle  has  become  raised  by  serum,  "  snip  it,  and  apply 
to  the  one  from  whence  a  permanent  discharge  is  required  a 
piece  of  zinc-foil,  and  to  the  other  a  piece  of  silver ;  connect 
them  by  a  copper-wire,  and  cover  them  with  a  common  water- 
dressing  and  oiled  silk.  If  the  zinc  plate  be  raised  in  a  few 
hours,  the  surface  of  the  skin  will  look  white,  as  if  rubbed 
over  with  nitrate  of  silver.  In  forty-eight  hours  a  decided 
eschar  will  appear,  which  (still  keeping  on  the  plates,)  will 
begin  to  separate  at  the  edges  in  four  or  five  days.  The 
plates  may  then  be  removed,  and  the  surface  where  the  silver 
was  applied  will  be  found  to  be  completely  healed.  A  com- 
mon poultice  may  be  placed  upon  the  part  to  which  the  zinc 
was  applied,  and  a  healthy  granulating  sore,  with  well-defined 
edges,  freely  discharging  pus,  will  be  left." 

Dr.  Bird's  explanation  of  this  interesting  phenomenon  is, 
that  the  chloride  of  sodium  contained  in  the  fluid  exuded  be- 
neath the  cuticle  is  decomposed;  —  the  chlorine  being  evolved 
at  the  zinc  plate,  forms  with  the  metal  a  chloride  of  zinc, 
which  is  an  escharotic. 

This  means  will  of  course  be  applicable  whenever,  for  any 
purpose,  it  is  desired  to  destroy  a  surface,  whether  of  the  skin 
or  of  an  ulcer.  (London  Medical  Gazette,  vol.  iv.,  N.  S. 
184T,  p.  981.) 


ACUPUNCTURE. 

For  convenience-sake,  the  modes  of  practising  acupuncture 
and  vaccination  will  be  considered  in  connexion  with  this 
chapter,  although  neither  of  these  operations  are  performed 
with  a  view  of  effecting  cutaneous  irritation  merely. 


OF    ACUPUNCTURE.  279 

ACUPUNCTURE.  —  The  instrument  by  which  this  is  accom- 
plished is  a  needle  about  two  inches  long,  having  a  cylindri- 
cal shaft  tapering  towards  one  extremity  to  a  sharp  point ; 
the  other  end  is  received  into  a  small  handle  of  ivory  or  of 
steel,  or  it  is  simply  coated  with  sealing-wax.  The  needle  is 
made  sometimes  of  steel,  sometimes  of  one  of  the  precious 
metals.  In  introducing  it,  the  instrument  is  held  perpendi- 
cularly upon  the  surface,  and  forced  through  the  skin  to  the 
requisite  depth  by  a  rotatory  movement,  combined  with  a 
sufficient  pressure  upon  the  point.  The  punctures  are  made 
in  muscular,  tendinous,  or  aponeurotic  tissues,  whichever  may 
be  the  seat  of  suffering,  and  the  depth  of  the  puncture  must 
of  course  depend  upon  the  position  of  the  tissue  affected.  It 
is  advisable  to  allow  the  needle  to  remain  in  the  part  for  a 
length  of  time,  as  for  a  half  hour,  an  hour,  or  even  longer, 
since  a  more  permanently  beneficial  effect  is  thus  produced 
than  when  the  instrument  is  withdrawn  at  once.  The  needle 
may  be  extricated  by  making  slight  pressure  upon  the  sur- 
face, and  withdrawing  the  instrument  with  a  rotatory  move- 
ment. 

No  accident  follows  the  operation,  generally ;  rarely  more 
than  a  drop  of  blood  appears  at  the  puncture ;  the  chief  ves- 
sels and  nerves  are  always  avoided,  and  the  puncture  should 
not  penetrate  any  of  the  important  cavities,  or  viscera. 

Electro-puncture  consists  in  passing  through  needles,  intro- 
duced as  above  described,  a  current  of  electricity  collected  in 
a  Leyden  jar,  or  generated  in  a  small  voltaic  pile,  which  is 
connected  with  the  needles  by  a  metallic  wire  passing  to  each 
pole  of  the  battery. 

Both  these  varieties  of  acupuncture  are  frequently  of  ser- 
vice in  the  treatment  of  neuralgia,  and  of  rheumatism  un- 
attended with  inflammation ;  in  the  treatment  of  indolent 
tumours  also,  by  promoting  their  removal  by  absorption  ; 
in  the  cure  of  local  paralysis,  &c.,  &c.  Simple  acupuncture 
is  very  often  resorted  to  in  order  to  evacuate  anasarcous  col- 
lections. 

Local  pain  of  a  violent  neuralgic  character  may  be  re- 
lieved in  many  instances,  and  speedily,  by  rubbing  upon  the 
surface  thus  punctured  a  solution  of  sulphate  of  morphia,  con- 
taining several  grains  in  each  ounce  of  water. 


280  OF    VACCINATION 


VACCINATION. 

The  operation,  as  generally  practised,  consists  in  inserting 
beneath  the  cuticle,  at  some  convenient  point,  the  matter  of 
the  cow-pock. 

Several  methods  have  been  adopted  for  the  collection  and 
preservation  of  vaccine  matter.  If  it  were  practicable,  the 
simplest  method  would  be,  to  transfer  the  liquid  vaccine 
lymph  from  the  arm  of  one  child  to  that  of  another  —  upon 
whom  the  operation  is  about  to  be  performed.  But  since  this 
proceeding  is  not  always  convenient  or  possible,  the  virus 
must  be  collected  and  preserved  in  the  liquid  state,  or  in  the 
form  of  the  dry  crust.  In  the  liquid  state,  it  may  be  pre- 
served between  two  small  plates  of  glass.  Or  capillary  tubes, 
having  a  bulb  at  one  extremity,  may  be  placed  in  contact,  at 
the  open  end,  with  the  lymph  of  the  fifth  or  sixth  dry  vesi- 
cle,—  the  air  in  the  bulb  having  been  rarefied  by  the  warmth 
of  the  hand,  or  of  the  mouth,  is  again  permitted  to  cool  and 
contract,  when  the  fluid  will  enter ;  so  soon  as  a  sufficient 
quantity  has  collected  in  the  bulb,  the  extremity  of  the  tube 
should  be  sealed  in  the  flame  of  a  spirit-lamp  and  blow-pipe. 
But  the  most  convenient  method  to  be  pursued  in  the  pre- 
servation of  the  virus  is,  to  permit  the  lymph  to  dry,  either 
on  points  of  ivory,  or  as  a  scab  upon  the  surface  at  the  site 
of  the  vaccination.  If  the  latter  be  adopted,  the  crust  may 
be  very  well  kept  by  being  enveloped  in  tin-foil,  or  between 
two  pieces  of  wax  excavated  to  receive  it.  The  author  has 
recently  vaccinated  several  children  with  a  scab  which  has 
been  thus  preserved  for  two  years ;  the  vesicle  was  developed 
in  each  case,  and  passed  through  its  customary  phases  with 
perfect  regularity. 

The  operation  may  be  performed  with  a  thumb-lancet,  or 
with  a  lancet  made  expressly  for  vaccinating ;  this  differs 
from  the  thumb-lancet  only  in  being  smaller.  The  virus  may 
be  introduced  beneath  the  cuticle,  by  means  of  lateral  punc- 
tures made  with  the  point  of  the  lancet;  or,  the  skin  having 
boen  rendered  tense  between  the  thumb  and  fore-finger  of  the 
left  hand,  placed  upon  the  part  of  the  surface  selected  for  the 
seat  of  the  operation  (generally  the  arm  above  the  elbow), 


OF    VACCINATION.  281 

the  cuticle  may  be  removed,  over  a  minute  space,  by  slight 
scratches  with  the  point  of  the  lancet,  crossing  and  recrossing 
each  other  until  the  vascular  surface  is  reached,  (blood  being 
just  made  to  appear,)  and  then  the  virus  be  applied  thereon. 
If  the  liquid  lymph  be  used,  it  is  simply  requisite  to  moisten 
the  lancet  therewith,  and  to  apply  the  blade  upon  the  exposed 
surface ;  if  the  points  of  ivory  be  employed,  one  of  them  may 
be  inserted  beneath  the  cuticle,  according  to  the  first  method 
of  operating,  or  placed  in  contact  with  the  denuded  surface, 
if  the  second  plan  be  adopted  ;  if  the  scab  be  selected,  a  small 
particle  of  it  should  be  reduced  to  powder  and  moistened  with 
a  little  water,  being  rubbed  to  a  pulpy  consistence  by  the  aid 
of  the  lancet-blade,  which  should  now  be  wiped  upon  the 
abraded  skin,  so  that  a  sufficient  portion  of  the  vaccine  mat- 
ter shall  come  in  contact  with  the  absorbing  surface.  After 
the  operation  is  completed,  the  part  should  be  left  uncovered 
until  the  surface  has  become  perfectly  dry ;  the  subsequent 
stages  which  the  vaccine  disease  assumes,  in  the  development 
and  maturation  of  the  vesicle,  should  be  carefully  watched,  in 
order  that  a  correct  opinion  may  be  had  as  to  the  efficacy  of 
the  operation. 


24* 


CHAPTER  IV. 

ON  THE   METHODS   OF  ARRESTING  HEMORRHAGE. 

THE  occurrence  of  bleeding,  as  an  accident,  or  in  connexion 
with  an  operation,  always  claims  the  prompt  attention  of  the 
surgeon,  and  often  demands  the  manifestation  of  all  his  skill 
and  self-possession. 

In  the  consideration  of  this  subject  we  shall  describe  the 
methods  found  most  efficacious  in  arresting  haemorrhage,  and 
state  the  circumstances  to  which  each  is  most  applicable. 

1.  By  the  action  of  cold.     This  is  the  simplest  method  of 
arresting  the  flow  of  blood  from  a  wound,  and  its  efficacy  is 
exemplified  daily,  the  mere  evaporation  which  takes  place  at 
the  surface  of  the  wound  reducing  the  temperature  of  the  part, 
thereby  favouring  the  coagulation  of  the  blood  and  exercising 
a  degree  of  constriction  upon  the  bleeding  vessels.    This  effect 
may  be  increased  by  exposing  the  divided  tissues  to  a  current 
of  air,  naturally  or  artificially  excited.     Bleeding  from  super- 
ficial wounds,  or  abrasions,  when  no  vessel  of  notable  size  is 
opened,  may  generally  be  checked  by  this  simple  mode. 

The  application  of  cold  water,  or  of  ice,  to  the  bleeding  sur- 
face, or  to  its  immediate  vicinity,  is  still  more  effectual,  and 
will  very  often  arrest  haemorrhage  from  small  arteries.  Dr. 
G.  N.  Burwell,  of  Buffalo,  informed  the  author  very  recently, 
that  he  had  succeded  in  stopping  profuse  bleeding  from  a  deep 
transverse  wound  of  the  palm  of  the  hand,  by  the  constant  ap- 
plication of  ice  during  twenty-four  or  thirty-six  hours.  The 
ice  may  be  placed  in  direct  contact  with  the  wound,  or  it  may 
be  enclosed  in  linen,  or  in  a  bladder.  If  cold  water  is  used, 
it  may  be  simply  laid  upon  the  surface  in  saturated  lint,  or  it 
may  be  employed  by  douche,  or  irrigation ;  the  latter  is  the 
most  efficacious.  Evaporating  lotions  may  be  found  effectual 
sometimes,  in  the  absence  of  ice. 

2.  By  the  application  of  astringents,  and  styptics.     These 
act,  probably,  in  a  twofold  manner, — upon  the  organic  proper- 

(282) 


METHODS    OF    ARRESTING    HEMORRHAGE.      283 

ties  of  the  bleeding  vessels  and  surrounding  tissues,  and  also 
upon  the  blood  itself;  causing  by  the  former,  a  constriction, 
a  greater  or  less  degree  of  closure,  of  the  vessels, — and  by  the 
latter,  favouring  coagulation  of  the  effused  blood  which  me- 
chanically prevents  the  escape  of  more.  There  are  many  sub- 
^stances  which  induce  coagulation  of  blood,  not  by  any  chemi- 
cal, or  vital,  agency  which  they  exert,  or  develope,  but  simply 
by  opposing  the  flow  at  numerous  points,  so  that  it  becomes 
retarded,  and  then  coagulates  by  its  own  inherent  properties ; 
such  are  cob-web,  filaments  of  lint,  powdered  sugar,  and  other 
similar  domestic  remedies. 

The  astringent  and  styptic  applications  which  have  been 
found  most  serviceable  for  the  purpose  under  consideration 
are,  powdered  alum  ;  powdered  galls  ;  sulphate  of  copper  and 
of  zinc,  also  in  powder;  creasote,  and  the  tincture  of  the  mu- 
riate of  iron.  Fluids  act  most  rapidly  because  they  come  most 
speedily  in  contact  with  the  points  from  which  the  blood  es- 
capes ;  they  are  applied  usually  by  means  of  a  brush  of  camel's 
hair,  or  upon  a  feather,  passed  over  the  surface  ;  or  by  satu- 
rating with  them  a  piece  of  lint  which  is  pressed  lightly  upon 
the  part.  If  a  powder  is  used,  it  may  be  sprinkled  over  the 
surface,  or  retained  upon  it  by  gentle  pressure.  The  tincture 
of  the  muriate  of  iron  is  probably  the  best  of  these  means. 
These  agents  will  generally  suffice  to  arrest  bleeding  from  vas- 
cular surfaces,  no  large  vessel  being  opened, — for  example,  in 
haemorrhage  from  the  mucous  membrane  lining  the  nostrils, 
in  bleeding  ulcers  on  the  neck  of  the  uterus,  in  bleeding  hse- 
morrhoidal  tumours. 

Matico,  a  plant  growing  in  South  America,  has  been  lately 
recommended  as  possessed  of  particular  efficacy  in  arresting 
haemorrhage.  Dr.  Ruschenberger,  of  the  U.  S.  Navy,  has 
employed  it  in  a  large  number  of  cases,  and  bears  strong  testi- 
mony to  its  value  as  a  haemostatic  agent.  He  used  it  success- 
fully to  arrest  bleeding  from  a  bubo  which  had  been  opened 
by  the  knife,  and  from  which  the  blood  issued  in  full  and  free 
jets,  long-continued  and  well-applied  pressure  having  failed  to 
arrest  it ;  it  likewise  caused  the  cessation  of  bleeding  from  hae- 
morrhoids removed  by  incision,  which  had  produced  trouble- 
some haemorrhage,  resisting  other  applications  of  various  kinds. 
The  mode  which  Dr.  Ruschenberger  advises  for  its  employ- 
ment is,  to  break  the  dried  leaves  into  a  coarse  powder  and  to 


284      METHODS    OF    ARRESTING    HEMORRHAGE. 

form  with  this,  by  the  aid  of  water,  a  pultaceous  mass,  which 
should  then  be  placed  upon  the  bleeding  surface  and  retained 
there  by  very  light  pressure, — a  pressure  which  would  not 
prove  sufficient,  of  itself,  to  arrest  the  bleeding.  Dr.  R.  speaks 
highly  of  the  efficacy  of  matico,  taken  in  infusion,  for  sponta- 
neous haemorrhage,  having  proved  its  value  in  profuse  menor- 
rhagia,  in  haemophthisis,  and  similar  cases. 

3.  By  cauterization.  This  produces  an  eschar,  sealing  up 
the  orifice,  or  orifices,  from  which  the  blood  escapes.  So  long 
as  the  eschar  remains  adherent  to  the  vessel,  it  presents  a  me- 
chanical impediment  to  the  further  escape  of  blood  ;  but  when, 
in  the  process  of  nature,  the  slough  has  become  detached,  the 
haemorrhage  will  recur,  unless  the  vessel  has  become  perma- 
nently obliterated  from  its  open  extremity  as  high  up  as  the 
first  branch  above  it ;  hence  the  patient  should  be  carefully 
watched  about  the  time  at  which  the  slough  seems  inclined  to 
separate,  lest  the  bleeding  should  return  unexpectedly.  In 
the  choice  of  a  cauterizing  agent,  therefore,  some  one  must  be 
selected  which  shall  produce  an  eschar  sufficiently  deep  to  re- 
main adherent,  until  nature  shall  have  accomplished  the  per- 
manent closure  of  the  vessel  between  the  points  mentioned. 
The  fact  should  be  borne  in  mind  that,  the  application  of  any 
caustic  will  prevent  the  possibility  of  union  of  the  wound  by 
the  first  intention.  The  actual,  or  the  potential  cautery,  may 
be  used. 

In  employing  the  actual  cautery,  the  metal,  generally  iron, 
should  be  heated  to  whiteness  and  then  applied  upon  the  sur- 
face for  a  few  seconds  only  ;  both  of  these  precautions  are  ne- 
cessary, for  if  the  iron  be  of  a  lower  temperature  than  that 
which  constitutes  '  white  heat,'  the  eschar  occasioned  by  it  is 
less  perfect  and  its  action  is  more  painful ;  and  if  the  cautery 
be  kept  too  long  in  contact  with  the  tissues,  it  adheres  to  them, 
and  when  it  is  withdrawn,  it  removes  the  eschar  with  it, 
thereby  destroying,  of  itself,  the  good  which  it  had  accom- 
plished. 

The  form  of  the  cautery  should  be  adapted  to  the  character 
of  the  part  to  which  it  is  to  be  applied :  thus,  if  the  wound  be 
narrow,  and  the  bleeding  vessel  lay  at  the  bottom  of  it,  the 
iron  should  be  sufficiently  long  and  small  to  reach  to  the  ori- 
fice of  the  vessel.  The  annexed  drawing  illustrates  some  of 
the  most  common  forms  of  the  actual  cautery.  (Fig.  128.) 


METHO.DS   OF  ARRESTING  HEMORRHAGE.      285 
FIG.  128. 


The  actual  cautery  is  now  rarely  used  to  arrest  haemorrhage, 
this  object  being  almost  always  effected  by  some  other  means 
more  simple,  and  less  shocking  in  appearance.  The  cases  in 
which  it  is  still  recommended  are,  in  operations  upon  the  bones 
of  which  the  medullary  membrane  is  excessively  vascular ;  in 
the  bleeding  which  sometimes  follows  the  extraction  of  a  tooth, 
and  in  others  similar. 

Of  the  potential  cauteries,  those  most  used  are,  the  nitrate 
of  silver,  and  concentrated  sulphuric  acid.  The  former  may 
be  employed  in  the  solid  state,  its  extremity  having  been 
previously  more  or  less  pointed,  by  friction  upon  the  surface 
of  a  wet  rag,  or  in  concentrated  solution,  as  of  9j  to  a  fluid- 
ounce  of  water,  applied,  as  is  the  acid,  by  means  of  a  brush. 
The  efficacy  of  lunar-caustic,  in  stick,  in  arresting  bleeding 
from  leech-bites,  has  already  been  mentioned.  The  solution 
of  the  salt,  or  the  sulphuric  acid,  is  often  of  service  in 
haemorrhage  from  incised  or  ulcerated  surfaces,  which  are  too 
much  removed  from  sight  to  admit  of  nice  inspection  and 
handling,  and  from  those  which  present  no  apparent  vessel, 
or  bleeding  point :  thus  bleeding  ulcers  or  wounds  on  the  neck 
of  the  uterus  are  sometimes  treated,  a  speculum  vaginae  being 
used  to  assist  the  surgeon  in  the  application  of  the  remedy. 

4.  By  directly  obliterating  the  vessel  which  gives  out  the 
blood.  This  may  be  a  temporary  or  a  permanent  effect,  as 
the  means  used  are  temporary  or  permanent  in  their  action. 
Transient  obliteration  may  be  best  induced  by  simple  pressure 
upon  the  vessel ;  permanent  occlusion  is  produced  by  torsion, 
and  the  use  of  the  ligature.  The  former  is  applicable  to  all 


286     METHODS   OF  ARRESTING  HAEMORRHAGE. 

varieties  of  accidental  bleeding,  whether  it  be  arterial,  venous, 
or  capillary ;  the  ligature  and  torsion  are  employed  almost 
exclusively  in  arterial  haemorrhage. 

PRESSURE. — The  mode  of  making  the  requisite  compression 
varies  according  to  circumstances. 

If  there  be  a  wound  bleeding  moderately,  or  if  the  blood 
be  of  a  venous  character,  it  very  often  happens  that  the 
haemorrhage  is  arrested  by  the  mere  apposition  of  the  edges 
of  the  wound,  if  it  be  an  incised  wound ;  or  by  the  simple 
pressure  upon  it  of  the  dressings,  if  it  be  such  as  not  to  admit 
of  apposition  of  its  lips.  When  the  divided  vessels  are  of  a 
larger  calibre  and  bleed  more  freely,  pressure  should  be  made 
with  the  aid  of  a  compress  and  adhesive  plaster,  or  a  roller 
(as  in  fig.  125).  Direct  pressure  upon  a  wound  is  objection- 
able, particularly  if  it  be  a  lacerated  or  contused  wound,  or 
if  much  pressure  be  required  to  produce  the  desired  effect, 
because  it  will  interfere  with  the  reparation  of  the  injury,  and 
may  induce  sloughing.  When  positive  pressure  is  to  be  ex- 
erted for  the  sake  of  the  compression,  the  vicinity  of  the 
wound  should  therefore  be  selected  as  the  site  of  its  applica- 
tion, rather  than  the  wound  itself. 

Pressure  is  employed  also  to  prevent  haemorrhage  during 
operations,  as  in  amputations,  and  likewise  in  accidental 
wounds,  as  a  temporary  expedient,  until  some  more  perma- 
nent measure  be  adopted.  For  this  purpose,  the  compressive 
force  may  be  applied  at  any  point  at  which  it  can  be  most 
effectually  and  conveniently  exercised.  The  simplest  method 
of  instituting  this  measure,  is  to  press  the  fingers  upon  the 
course  of  the  vessel  through  which  the  circulation  is  to  be 
arrested.  With  this  object,  some  point  should  be  selected 
where  the  vessel  is  readily  felt  pulsating ;  and,  if  possible, 
this  point  should  be  favourably  situated  with  regard  to  some 
bony  support,  so  that  the  vessel  can  be  pressed  against  the 
latter,  and  thus  be  completely  obliterated.  For  example,  the 
facial  artery  should  be  compressed  against  the  edge  of  the 
lower  jaw,  at  the  anterior  margin  of  the  masseter  muscle ; 
the  temporal  and  occipital  arteries,  at  any  point  of  their 
course,  at  which  they  can  be  felt;  the  brachial  artery,  by 
grasping  the  biceps  muscle,  at  the  middle  of  the  arm,  between 
the  fingers  and  thumb  of  the  right  hand,  and  at  the  same 
pressing  the  artery  against  the  bone  with  the  points  of 


METHODS   OF  ARRESTING   HAEMORRHAGE.     28T 

the  fingers,  on  the  inner  side  of  the  muscle,  (fig.  129 ;)  the 
axillary  artery,  by  thrusting  the  fingers, — their  points  approx- 
imated,—  into  the  axilla,  and  forcing  the  artery  against  the 


FIG.  130. 


head  of  the  humerus ;  the  subclavian  artery,  by  pressing  the 
thumb  down  upon  the  vessel,  behind  the  clavicle,  upon  the 
point  at  which  the  artery  crosses  the  first  rib  on  the  external 
side  of  its  tubercle ;  generally,  the  artery  cannot  be  suffi- 
ciently well  compressed  by  the  thumb,  and  it  is  necessary, 
therefore,  to  employ  some  instrument  for  the  purpose,  as  a 
common  door-key,  of  which  the  ring  should  be  wrapped  with 
a  piece  of  linen,  and  then  pressed  upon  the  vessel,  as  above 
advised ;  the  femoral  artery,  by  placing  one  thumb  upon  the 
vessel,  at  the  point  where  it  crosses  the  ilium  to  descend  the 
thigh,  and  making  the  requisite  pressure  by  the  other  thumb 
acting  upon  the  first,  (fig.  130 ;)  the  abdominal  artery,  by 
causing  the  patient  to  occupy  a  position  whereby  his  back  and 
thighs  shall  be  flexed,  and  the  abdominal  parietes  relaxed,  and 
then  pressing  the  artery  against  the  spinal  column. 


288     METHODS   OF  ARRESTING   HEMORRHAGE. 

But,  although  it  is  not  necessary  in  most  cases,  to  exert 
much  force  with  the  fingers,  the  muscles  are  very  soon  fa- 
tigued, so  that  the  pressure  becomes  unsteady  and  uncertain, 
if  it  be  maintained  for  any  length  of  time ;  and  moreover, 
the  fingers  are  liable  to  become  displaced  by  any  sudden 
movement  of  the  patient ;  hence  the  necessity  of  employing 
some  compressing  force  which  shall  not  be  liable  to  these 
objections.  The  tourniquet  offers  such  advantages. 

The  tourniquet,  in  its  most  common  form,  is  very  well 
represented  in  the  annexed  drawing,  (fig.  131.)  It  is  so  con- 
trived, that  when  the  strap  is  buckled  around  the  limb,  by 

FIG.  131. 


turning  the  screw  the  soft  parts  are  compressed  and  the  pad 
forced  upon  the  artery.  Before  applying  the  tourniquet,  the 
surgeon  should  examine  it  carefully,  to  see  that  it  is  in  good 
order, — the  screw,  strap  and  buckle  strong, — so  that  it  shall 
not  fail  when  most  needed.  A  firm  pad  should  be  made,  of 
a  cylindrical  shape,  for  application  over  the  artery,  and  the 
strap  secured  around  the  limb.  The  screw  should  not  be 
turned  too  rapidly,  and  no  more  compression  should  be  exer- 
cised about  the  limb  than  may  be  necessary  to  prevent  the 


METHODS   OF  ARRESTING  HAEMORRHAGE.      289 

flow  of  blood  below  the  point  of  pressure.  A  long-sustained 
application  of  this  instrument  is  productive  of  considerable 
pain,  and  therefore  it  should  be  avoided. 

The  points  upon  which  the  tourniquet  is  applied  to  the 
limbs  are  not  fixed.  Mr.  Fergusson  recommends  those  indi- 
cated in  the  accompanying  drawings  (figs.  132,  133,  134), 


FIG.  132. 


FIG.  133. 


290      METHODS   OF  ARRESTING  HEMORRHAGE. 


preferring  compression  of  the  artery  in  the  popliteal  region, 
when  the  leg  is  to  be  amputated  below  the  knee,  rather  than 
of  the  femoral  artery  at  the  upper  part  of  the  thigh. 

An  'impromptu'  tourniquet,  for  use  in  emergencies,  con- 
sists of  a  cravat,  in  the  middle  of  which  a  knot  is  formed ;  the 
cravat  is  made  to  encircle  the  limb,  the  knot  corresponding  in 
situation  with  the  artery :  the  two  extremities  are  then  tied 
together,  a  piece  of  stick  inserted  between  them  and  made  to 
revolve  until  the  limb  is  sufficiently  compressed.  This  is  com- 
monly called  the  field-tourniquet.  (Fig.  135.) 


FIG.  135. 


FIG.  136. 


An  objection  to  the  ordinary  tourniquet  is,  that  it  con- 
stricts the  whole  limb,  preventing  the  circulation  through  the 
veins  as  well  as  through  the  arteries,  causing  considerable 
pain  and  swelling,  if  continued  beyond  a  short  time.  To  ob- 
viate this  difficulty,  compressing  instruments  of  various  kinds 
have  been  invented :  they  have  not,  as  yet,  arrived  at  such 
perfection  as  to  be,  on  the  whole,  preferable  to  the  tourniquet 
in  common  use.  The  compressor  of  Dupuytren  "  consists  of 


METHODS   OF  A  R  R  E  S  T  I  N  G   H^IM  0  R  R  H  A  GE.      291 

two  steel-plates  (fig.  136),  half  an  inch  broad,  curved  and 
joined  at  the  centre  of  the  instrument  in  such  a  manner  as  to 
allow  of  the  curve  being  increased  or  diminished  at  will.  To 
these  plates  two  others,  which  support  pads,  are  Attached: 
one  of  the  pads  is  movable,  the  other  fixed;  and  in  applying 
the  instrument,  the  movable  one  is  placed  over  the  artery,  the 
other  rests  upon  the  opposite  side  of  the  limb.  The  pressure 
is  made  by  the  movable  pad,  and  is  regulated  by  a  screw." 
(Liston's  and  Mutter's  Lectures  on  Surgery,  p.  42.) 

Dr.  Dorsey  (Elements  of  Surgery,  vol.  i.,  p.  57)  mentions 
a  very  simple  and  ingenious  expedient  by  which  the  same 
effect  was  attained.  "  The  patient  was  a  child,  in  whom, 
several  unavailing  attempts  had  been  made  to  tie  up  the 
divided  vessel  (an  artery  in  the  foot),  and  the  wound  was  in  a 
state  of  great  inflammation.  A  compress  was  applied  over 
the  trunk  of  the  anterior  tibial,  and  another  over  that  of  the 
posterior  tibial  artery,  about  two  inches  above  the  ankle; 
over  these  a  strip  of  sheet  copper  was  passed  around  the  leg, 
and  a  tourniquet  applied  over  the  copper :  when  the  tourni- 
quet was  tightened,  the  tibial  arteries  were  compressed  and 
the  bleeding  ceased,  the  copper  preventing  the  tourniquet 
from  compressing  any  other  vessel,  so  that  the  circulation  in 
the  foot  was  not  interrupted.  In  a  few  days  the  wound  healed 
without  any  recurrence  of  haemorrhage." 

Since  the  treatment  of  aneurism  by  compression  has  become 
a  standard  measure,  great  improvements  have  been  made  in 
the  construction  of  tourniquets,  and  the  great  desideratum, 
seems  to  have  been,  to  a  considerable  extent,  gained,  viz.:  to 
exercise  a  moderate,  but  sufficient  compressive  force  upon 
the  artery,  without  interfering  materially  with  the  return  of 
the  blood  through  the  veins.  The  fact  has  become  established, 
that,  to  cure  an  aneurism,  it  is  not  essential  absolutely  to  pre- 
vent the  arterial  circulation,  but  merely  to  reduce  it  to  a  cer- 
tain sluggish  current.  Several  instruments  have  been  con- 
trived which  produce  this  effect;  and  they  can,  moreover,  so 
completely  obliterate  the  artery,  as  to  be  adapted  for  use  in 
amputations,  or  in  other  cases  where  it  is  necessary  that  the 
arterial  flow  should  be  stopped,  for  the  time.  The  Dublin 
Surgeons,  particularly  Drs.  Bellingham,  Carte  and  Tafnell, 
deserve  most  of  the  credit  for  these  improvements. 

Fig.  137  represents  an  instrument  of  this  kind,  designed 


292      METHODS   OF   ARRESTING   HAEMORRHAGE. 

for  application  to  the  middle  of  the  thigh ;  and  fig.  138,  one 
for  the  groin. 


FIG.  137 


FIG.  138. 


METHODS  OF  ARRESTING   HEMORRHAGE.    293 

If  employed  simply  for  the  purpose  of  arresting  or  prevent- 
ing haemorrhage,  only  one  tourniquet  or  compressor  will  be 
required.  But  if  applied  for  the  cure  of  aneurism,  it  is  con- 
sidered better  to  use  two,  so  that  when  the  pressure  caused  by 
one  becomes  disagreeable,  the  other  can  be  brought  into  ser- 
vice immediately. 

Dr.  Carte's  compressor,  as  represented  in  fig.  139,  possesses 

Fm.  139. 


this  peculiar  feature,  that,  in  addition  to  the  common  screw 
force,  a  certain  degree  of  elasticity  is  gained  by  the  introduc- 
tion of  bands  of  vulcanized  India-rubber. 

PLUGGING  of  the  divided  vessel,  or  of  a  wound,  is  sometimes 
resorted  to  for  arresting  the  flow  of  blood  when  other  means 
have  failed.  It  acts  by  compressing  the  vessel,  or  by  me- 
chanically stopping  its  orifice.  It  is  rarely  done  now,  except- 
ing occasionally  when  blood  continues  obstinately  to  flow  from 
the  cut  extremity  of  the  bones  in  amputation :  here  a  piece 
of  lint,  or  of  wood,  having  a  ligature  attached  to  it,  is  gently 
pressed  within  the  cavity  of  the  bone,  or  within  its  reticulated 
structure,  and  allowed  to  remain,  the  ligature  hanging  from 
between  the  edges  of  the  flap,  so  that  the  plug  may  be  re- 
moved when  it  has  fulfilled  its  intention. 
25* 


294      METHODS   OF  ARRESTING  HAEMORRHAGE. 

TORSION  is  now  but  little  resorted  to.  It  consists  in  twist- 
ing the  vessel  several  times  upon  its  axis,  so  as  to  rupture  its 
inner  and  middle  coats,  which  then  become  more  or  less 
inverted,  as  when  cut  by  a  ligature.  Many  methods  of  per- 
forming this  simple  operation  have  been  advised,  of  which  the 
simplest  is  probably  as  effectual  as  any.  The  artery  should 
be  seized  at  its  open  extremity  by  a  pair  of  serrated  forceps 
(fig.  140),  with  which  it  is  drawn  out  from  the  wound,  and 

FIG.  140. 


isolated  from  its  connexions  with  the  surrounding  tissues  ;  it 
is  then  held  in  the  grasp  of  a  pair  of  catch-forceps  placed 
across  its  axis,  at  the  distance  of  half  an  inch  from  its  open 
end,  and  twisted  several  times  in  the  direction  of  its  axis  by 
means  of  the  first  forceps  (fig.  141)  :  the  torsion  having  been 


HI. 


thus  accomplished,  the  vessel  is  returned  into  the  wound. 
This  is  not  generally  trusted  to  as  a  safe  and  certain  means 
of  arresting  haemorrhage,  excepting  in  the  instance  of  small 
arteries.  If  the  vessel  can  be  thus  seized  and  twisted,  a  liga- 
ture can  certainly  be  applied  to  it  as  well,  and  will  scarcely 
give  rise  to  more  irritation  than  the  portion  of  the  artery  thus 
violently  crushed  and  reduced  to  the  condition  of  a  foreign 
body  in  the  wound. 

The  LIGATURE  offers  the  most  safe  and  permanent  means 


METHODS   OF  ARRESTING  HAEMORRHAGE.      295 

of  obliterating  an  artery  of  a  size  sufficient  to  admit  of  its 
application. 

The  object  had  in  view  in  the  employment  of  the  ligature 
is,  the  division  of  the  internal  and  middle  coats  of  the  artery ; 
these  retract  within  the  canal,  giving  the  latter  the  appear- 
ance of  a  cone,  of  which  the  apex  points  towards  the  ligature. 
The  cavity  of  the  vessel,  from  the  ligature  to  the  first  branch 
above  it,  becomes  filled  with  a  coagulum  of  blood,  and  the 
same  coagulating  process  takes  place  in  the  blood  which  has 
been  eifused  outside  of  the  vessel ;  soon,  however,  a  perma- 
nent obliteration  occurs,  from  a  vital  process,  some  degree  of 
inflammation  and  exudation  of  plastic  matter  being  occasioned 
by  the  irritation  of  the  ligature,  and  a  complete  consolidation 
of  the  tube  ensuing  from  union  of  the  internal  tunic  of  the 
artery  with  the  organizable  mass  within  it. 

Many  substances  have  been  recommended  as  materials  for 
the  ligature.  It  has  been  supposed  that  leaden  ligatures 
excite  less  irritation  in  the  midst  of  the  tissues  than  those  of 
any  other  material ;  ligatures  made  of  animal  fibre,  as  of  the 
sinew  of  the  deer,  have  been  supposed  to  be  removed  by 
absorption  at  the  point  at  which  they  are  tied ;  but  these  are 
probably  mistaken  ideas ;  no  one  now  thinks  it  advisable  to 
incur  the  trouble  of  preparing  ligatures  of  such  materials,  for 
the  sake  of  any  advantage  which  fancy  may  attribute  to  them 
over  the  ordinary  ligature,  made  of  saddler's  silk,  or  of  com- 
mon flaxen  thread. 

A  single  strand  of  strong  saddler's  silk,  or  of  good  home- 
spun thread,  will  answer  for  application  to  small  arteries ; 
but  when  the  vessel  is  larger,  the  ligature  should  be  corre- 
spondingly more  thick,  as  of  from  two  to  four  strands.  These 

FIG.  142. 


should  be  well  waxed,  and  twisted  firmly  and  roundly,  in 
order  to  cut  the  coats  of  the  artery,  as  before  mentioned,  a 
flattened  ligature  not  effecting  this  object.  Hence  also  in 


296      METHODS   OF  ARRESTING  HEMORRHAGE. 

applying  the  ligature,  the  knot  must  be  drawn  tightly.     For 
the  purpose  of  seizing  the  artery,  in  order  to  isolate  and  tie 
it,  the  forceps  figured  on  p.  295  (see  fig.  142),  having  a  toothed 
extremity  and  a  spring-catch  to  keep  this  closed,  is  a  very 
convenient  instrument,  less  so,  however,  than  the  tenaculum 
(fig.  143)  —  a  hook  with  a  long  curve  sharp  at 
FIG.  143.         the  point  —  which  is  inserted  into  the  mouth  of 
the  vessel,  and  by  which  the  latter  is  drawn  out. 
The  artery  being  thus  brought  within  reach,  it 
should  be  separated  from  its  connexions  with  the 
surrounding  tissues,  vessels,  and  nerves,  for  the 
space  of  a  few  lines,  and  the  ligature  applied 
around  it,  behind  the  tenaculum,  or  forceps.     It 
is  sometimes  proper  to  include  a  portion  of  the 
surrounding  tissues  in  the  knot,   as  when   the 
coats  of  the  artery  are  supposed  to  be  weakened 
from  inflammation  or  other  cause,  or  when  the 
mouth  of  the  vessel  which  bleeds  cannot  itself 
be  seen,  and  yet  the  surgeon  is  assured  that  it 
is  within  the  mass  which  he  has  raised  upon  his 
tenaculum,  or  by  his  forceps.     If  an  artery  of 
considerable  size  has  been  divided,  it  is  advisable 
to  tie  both  extremities,  as  otherwise  the  bleeding 
may  be  renewed  from  that  portion  of  the  vessel 
which  was  not  at  first  emitting  blood,  but  into 
which  an  anastomosing  current  has  afterwards 
discharged  itself:  this  precaution  is  particularly  necessary  in 

situations  where  the  anastomosis 
FIG.  144.  Of  arteries  is  known  to  be  com- 

mon, as  in  the  palm  of  the  hand 
and  on  the  foot. 

"The  sailor's  knot,"  as  it  is 
called,  is  the  one  best  calculated 
to  secure  the  artery  firmly  ;  it 
forms,  when  tightly  drawn,  a  flat 
knot  which  will  not  slip.  The 
accompanying  drawing  illustrates 
it  better  than  a  verbal  description.  (Fig.  144.) 

The  vessel  having  been  tied,  one  division  of  the  ligature 
should  be  cut  off  close  to  the  knot,  while  the  other  is  left 
hanging  from  the  wound.  When  many  vessels  have  been 


METHODS   OF  ARRESTING  HAEMORRHAGE.      297 

tied,  the  ligatures  thus  cut  should  be  grouped  together  and 
allowed  to  project  at  one  extremity  of  the  wound,  of  which 
the  edges  should  then  be  approximated :  when  one  of  the 
vessels  tied  is  of  large  size,  as  the  main  artery  of  a  limb,  the 
ligature  which  is  attached  to  it  should  be  indicated  by  a  knot 
made  at  its  free  extremity. 

The  length  of  time  during  which  the  ligature  remains  con- 
nected with  the  artery,  varies  according  to  the  size  of  the 
latter ;  generally,  from  five  to  twenty  days  may  be  considered 
as  elapsing  before  the  external  coat  of  the  vessel  becomes 
severed  at  its  point  of  constriction;  then  the  ligature  is 
loosened  and  falls  from  the  wound,  or  may  be  readily  drawn 
from  it.  After  the  usual  time  has  passed,  the  ligature  may 
be  gently  twisted  and  drawn  upon,  in  order  to  favour  its 
release,  as  sometimes  it  is  retained  by  the  granulations  in 
which  it  is  imbedded,  after  its  attachment  to  the  vessel  has 
ceased.  The  ligature  appertaining  to  the  largest  vessel 
should  be  handled  more  carefully  than  the  others.  The 
patient  should  be  carefully  watched  about  the  period  at  which 
the  ligatures  become  detached,  particularly  when  large  ves- 
sels have  been  tied,  lest  an  unexpected  haemorrhage  occur. 
Secondary  bleeding  requires  the  same  treatment  as  the 
primary. 

The  forceps  and  tenaculum  are  the  only  instruments  re- 
quired for  tying  a  vessel  which  presents  itself  at  the  surface 
of  a  wound.  But  it  often  happens  that  the  bleeding  artery 
ca'nnot  be  seen,  it  having  retreated  within  the  substance  of 
the  tissues :  it  then  becomes  necessary  either  to  slit  open  the 
tissues  from  the  point  at  which  the  haemorrhage  appears,  or 
to  cut  down  upon  the  course  of  the  vessel  above  the  wound, 
and  pass  a  ligature  around  it  at  this  point ;  the  former  is  a 
very  uncertain  and  disagreeable  operation,  the  latter  is  speedy, 
simple,  and  sure.  The  incision  having  been  made  at  the 
point  at  which  the  vessel  is  most  accessible,  the  object  is  to 
inclose  the  latter  in  the  loop  of  a  ligature  without  including 
the  accompanying  vein  or  nerve.  To  enable  the  surgeon  to 
effect  this,  several  instruments  have  been  contrived,  to  which 
the  term  aneurism-needles  has  been  applied.  The  simplest, 
and  one  which  answers  very  well  almost  always,  is  shown  in 
the  following  drawing  (fig.  *145) ;  it  needs  no  farther  descrip- 
tion. When  the  sheath  of  the  vessels  has  been  opened,  the 


298      METHODS   OF  ARRESTING  HEMORRHAGE. 

extremity  of  this  needle,  armed  with  a  ligature,  is  carried 
under  the  artery  and  brought  out  on  the  opposite  side,  when 
one  division  of  the  ligature  is  seized  between  the  fingers,  or 


FIG.  145. 


by  a  forceps,  and  drawn  out  upon  one  side,  while  the  other 
portion  follows  the  needle  as  it  is  removed  at  the  other  side 
of  the  wound:  the  vessel  is  then  tied,  as  above  advised. 
Professor  Gibson  has  invented  an  admirable  instrument  for 
passing  a  ligature  beneath  deep-seated  arteries.  It  consists 
of  a  flattened  canula  of  silver  sufficiently  strong,  curved 
rather  more  than  the  common  aneurism-needle  figured  above, 
and  fitted  to  a  handle  ;  through  the  interior  of  the  needle,  of 
which  one  extremity  of  the  cavity  opens  near  the  handle  on 
the  back  of  the  needle,  and  the  other  at  the  point,  a  piece  of 
watch-spring  passes,  having  an  eye  at  the  extremity  nearest 
the  handle,  and  terminating  at  the  other  end  in  a  head  of 
silver ;  the  ligature  is  placed  in  the  eye  of  the  spring,  and 
the  needle  is  passed  beneath  the  artery;  then  the  spring, 
which  is  considerably  longer  than  the  needle,  is  pushed 
through  the  cavity  of  the  instrument  and  appears  upon  the 
opposite  side  of  the  vessel,  carrying  the  ligature  with  it. 
Belloc's  instrument,  illustrated  by  fig.  148,  would  answer 
very  well  in  many  cases  where  the  artery  is  deeply  located. 
But  in  the  majority  of  instances,  a  ligature  can  be  readily 
passed  around  a  vessel  by  means  of  the  grooved  director  and 
the  eyed-probe,  which  are  in  every  one's  pocket-case.  The 
director  is  introduced  beneath  the  vessel,  and  carried  com- 
pletely across  the  wound,  so  as  to  rest  upon  the  edges  of  the 
latter,  the  artery  being  raised  upon  it ;  then  the  probe,  armed 
with  the  ligature,  is  slid  along  the  groove  of  the  director, 
beneath  the  artery,  and  drawn  out  upon  the  opposite  side 
with  the  ligature*.  In  some  instances,  the  bleeding  artery  is 


METHODS   OF  ARRESTING  HEMORRHAGE.      299 

concealed  behind  a  projecting  bone,  as,  for  example,  the 
internal  pudic  behind  the  rami  of  the  ischium  and  pubis  ;  in 
order  to  secure  this  vessel,  Dr.  Physick's  forceps,  having  a 
curved  needle  inserted  between  its  blades,  and  furnished  with 
a  hook  to  compress  its  handles,  will  be  found  the  most  conve- 
nient instrument.  (Fig.  146.) 

FIG.  146. 


The  surgeon  is  sometimes  called  upon  to  arrest  haemorrhage 
from  one  of  the  natural  canals,  or  cavities,  particularly  from 
the  nostrils  and  rectum. 

EPISTAXIS  occurring  in  individuals  of  a  hsemorrhagic  dia- 
thesis, frequently  induces  a  dangerous  degree  of  prostration. 
If  it  resists  the  use  of  cold  water,  or  ice,  applied  upon  the 
face  and  forehead,  or  on  the  back  of  the  neck,  and  if  astrin- 
gent powders  blown  into  the  nostrils,  or  injections  of^strin- 
gent  solutions,  fail  to  arrest  it,  the  nostrils  must  be  plugged. 
Stopping  the  anterior  orifices  of  these  cavities  will  not  suffice, 
as  the  blood  will  continue  to  escape  through  the  posterior 
nares;  both  must  be  stopped  therefore.  To  effect  this,  a 
piece  of  thin  wire  may  be  doubled  upon  itself,  and  the  folded 
end  introduced  along  the  floor  of  the  nostril,  from  before 
backwards,  until  it  has  traversed  the  passage  and  appears  at 
the  back  part  of  the  mouth;  the  surgeon  then  seizes  this 
looped  extremity  with  his  fingers,  or  forceps,  introduced  into 
the  mouth,  draws  it  forwards,  —  the  body  of  the  wire  still 
resting  on  the  floor  of  the  nostril, — and  passes  a  cord  through 
it,  the  centre  of  the  cord  corresponding  with  that  of  the  loop, 
while  the  ends  are  loose ;  the  wire  is  now  drawn  out  of  the 
nose  in  the  direction  by  which  it  was  introduced,  one  of  the 
divisions  of  the  ligature  emerging  with  it,  the  other  remain- 
ing in  the  surgeon's  hand ;  to  the  middle  of  this  portion  of 
the  cord  a  piece  of  lint  is  attached,  to  serve  as  the  plug, 
which  is  drawn  into  the  posterior  nares  by  the  first  division 
of  the  ligature ;  the  anterior  nares  are  next  to  be  plugged, 
by  inserting  lint,  and  the  haemorrhage  is  thus  effectually 


300     METHODS    OF    ARRESTING    HEMORRHAGE. 

FIG.  147. 


arrested.  At  the  end  of  two  or  three  days,  the  plugs  may 
be  removed,  the  posterior  being  drawn  out  by  means  of  the 
extremity  of  the  cord  which  has  been  left  hanging  from  the 
mouth.  (Fig.  147.)  See  Liston  and  Mutter,  p.  185. 

A  very  elegant  and  useful  instrument  for  plugging  the  pos- 
terior wares  has  been  invented  by  M.  Belloc.  It  is  a  canula 
of  silver,  A,  curved  very  much  like  a  catheter,  but  smaller. 
Through  this  canal  a  straight  stem  of  silver,  B,  is  introduced, 
to  which  is  attached  a  piece  of  watch-spring,  C,  terminating 
in  a  rounded  head  which  has  a  hole  drilled  in  it  for  the  in- 
sertion of  a  ligature.  The  free  extremity  of  the  straight 
rod,  B,  has  a  button  attached  to  it,  to  prevent  it  from  being 
drawn  out  of  the  canal ;  a  ring  is  soldered  to  the  inferior 
surface  of  the  canula,  to  aid  in  holding  the  instrument.  (Fig. 
148.)  In  introducing  this,  draw  the  watch-spring  entirely 


FIG.  148. 

A 


METHODS    OF    ARRESTING    HEMORRHAGE.     301 

within  the  tube  so  that  the  head  shall  form  a  smooth  convex 
extremity  to  the  instrument ;  then  the  tube  is  passed  along 
the  floor  of  the  nostril,  the  curve  presenting  downwards,  until 
its  head  reaches  the  extremity  of  the  naso-palatine  septum, 
when  the  watch-spring  is  pushed  out,  its  curved  form  causing 
it  to  find  its  way  directly  into  the  mouth ;  the  head  is  now 
drawn  forwards,  and  a  ligature,  with  a  plug,  of  lint  attached, 
is  passed  through  the  eye ;  the  remainder  of  the  operation  is 
managed  precisely  as  with  the  wire  above  spoken  of. 

In  HEMORRHAGE  from  the  RECTUM,  if  the  bleeding  vessel 
cannot  be  tied,  or  if  the  blood  comes  from  the  venous  plexus, 
astringent  powders  should  be  introduced;  if  these  fail,  a 
piece  of  bladder,  or  a  portion  of  the  intestine  of  some  animal, 
filled  with  pounded  ice,  should  be  inserted  within  the  sphincter 
ani  as  high  up  as  may  be  necessary.  But  the  presence  of 
these  foreign  matters,  as  well  as  of  the  effused  blood,  after  a 
time  excites  the  expulsive  efforts  of  the  muscles  and  they  are 
discharged.  In  a  case  of  this  kind  which  occurred  some 
years  ago  at  the  Pennsylvania  Hospital,  during  the  attend- 
ance of  Dr.  Thomas  Harris,  lately  chief  of  the  Naval  Bureau 
of  Medicine  at  Washington,  all  these  and  other  methods  of 
arresting  the  bleeding  failed ;  it  was  stopped  by  pressure 
upon  the  bleeding  point,  effected  by  means  of  a  finger  intro- 
duced into  the  rectum  and  held  there  for  many  hours,  so  long 
as  any  disposition  to  recurrence  of  bleeding  was  manifested ; 
—  so  soon  as  one  individual  became  fatigued  he  was  relieved 
by  another. 


26 


CHAPTER  V. 

ON  THE  DRESSING  OF  WOUNDS. 

THE  exposure  of  the  wound  for  inspection  constitutes  the 
first  step  in  its  treatment.  This  should  be  accomplished  very 
carefully,  after  the  manner  recommended  to  be  pursued  with 
regard  to  the  examination  of  fractures.  The  arrest  of 
haemorrhage  should  next  engage  attention ;  this  will  be 
eifected  by  some  of  the  means  already  adverted  to.  It  should 
he  borne  in  mind  that,  if  it  be  probable  that  the  wound  may 
be  made  to  close  by  direct  union  of  its  edges,  this  will  be 
prevented  by  the  application  of  styptics  or  escharotics  to 
check  the  bleeding,  and  therefore  if  the  simple  pressure  pro- 
duced by  the  apposition  of  the  edges  of  the  wound,  and  the 
means  used  to  secure  this,  be  not  sufficient  to  stop  the  flow 
of  blood,  the  ligature  should  be  applied  to  such  arteries  as 
bleed.  In  a  simple  incised  wound,  all  the  vessels  of  sufficient 
size  to  require  a  ligature  are  seen  pouring  out  blood ;  but  in 
wounds  accompanied  by  severe  contusions  and  lacerations, 
such  as  are  caused  by  the  bursting  of  fire-arms,  or  by 
machinery ;  it  is  not  at  all  uncommon  to  see  the  arteries  of 
the  largest  calibre  projecting  an  inch  or  more  from  the  midst 
of  the  torn  muscles,  and  vibrating  with  every  beat  of  the 
heart,  yet  not  emitting  a  drop  of  blood ;  in  such  cases,  liga- 
tures should  still  be  applied  to  these  arteries,  and  at  a  point 
where  their  coats  seem  to  be  uninjured ;  otherwise,  after  the 
wound  has  been  dressed,  and  the  vitality  of  the  injured 
parts  has  become  restored  by  warmth  and  rest,  profuse  bleed- 
ing will  occur  and  render  it  necessary  to  reopen  the  wound. 
It  is  neither  important  nor  advisable  to  tie  very  small  arte- 
ries, as  a  short  exposure  to  the  air  and  moderate  pressure 
will  generally  prevent  these  from  bleeding,  and  an  unneces- 
sary number  of  ligatures  will  interfere  very  much  with  the 
healing  of  the  wound. 

All  foreign  substances,  such  as  'dirt,  sand  and  gravel,  splin- 

(302) 


DRESSING    OF    WOUNDS.  303 

ters  of  wood,  fragments  of  clothes,  shot,  &c.,  should  be  care- 
fully removed  from  the  wound  by  the  aid  of  forceps,  or  with 
the  fingers,  or  by  allowing  a  stream  of  warm  water  to  flow 
gently  over  it.  Coagulated  blood  should  not  be  permitted  to 
remain  upon  the  injured  surface,  but  should  be  regarded  as  a 
foreign  body,  as  much  as  any  of  the  substances  enumerated. 
These  preliminary  measures  having  been  attended  to,  the  pro- 
per mode  of  dressing  the  wound  must  be  determined  upon ; 
and  in  the  selection  of  the  pieces  of  the  dressing,  it  should  be 
borne  in  mind  that  lightness  and  cleanliness  are  of  great  im- 
portance in  inducing  a  rapid  cure. 

If  the  wound  must  heal  by  granulations,  the  surgeon  should 
not  attempt  to  confine  its  edges  in  apposition,  as  a  consider- 
able degree  of  compression  must  be  exercised  to  effect  this, 
causing  pain  without  any  adequate  good.  He  should  be  con- 
tented with  simply  placing  the  limb,  or  other  part,  in  the 
most  favorable  position  to  ensure  ease  and  rest,  and  cover  the 
wound  with  a  suitable  dressing, —  cold  water  or  a  poultice, 
generally,  at  first,  to  allay  pain  and  to  combat  inflammation, 
followed,  when  these  symptoms  have  subsided,  by  the  appli- 
cation of  an  appropriate  cerate,  or  lotion ;  these  dressings 
should  be  retained  upon  the  surface  by  strips  of  adhesive 
plaster,  or  by  a  light  bandage.  In  severe  contused  and  lace- 
rated wounds,  the  best  primary  application  is  cold  water,  in 
the  form  of  irrigation.  (See  Part  I.) 

When  the  wound  is  of  such  a  character  as  to  afford  fair 
reason  to  expect  reparation  by  the  first  intention,  its  surfaces 
should  be  placed  in  apposition  along  their  whole  extent,  from 
the  bottom  to  the  top,  and  not  along  its  edges  merely ;  other- 
wise, though  the  latter  may  adhere  to  each  other,  granulations 
will  form  beneath  the  external  lips,  or  summit  of  the  wound, 
and  a  collection  of  matter  be  the  result,  which  will  eventually 
burst  through  the  adhesion  formed  above  it,  and  then  the  sur- 
face will  necessarily  be  disfigured  by  a  cicatrix  which  might 
have  been  avoided.  The  proper  apposition  of  the  walls  of  the 
wound  may  be  secured  by  the  use  of  adhesive  plaster,  by  su- 
ture, and  by  suitable  bandages, — by  one  or  all  of  these  means. 
Before  resorting  to  any  of  these,  however,  the  part,  particu- 
larly if  the  wound  be  deep,  should  be  placed  in  such  a  posi- 
tion as  shall  most  relax  the  muscles  involved :  thus,  for  exam- 
ple, if  there  be  an  incised  wound  cutting  across  the  muscles 


304  DEESSING    OF    WOUNDS. 

on  the  front  of  the  thigh,  the  limb  should  he  raised  upon  an 
inclined  plane,  and  the  hack  elevated  in  like  manner ;  with- 
out this  simple  precaution,  the  sides  of  the  wound  can  he 
hut  imperfectly  retained  in  apposition  by  any  compressive 
means. 

1.  The  mode  of  applying  strips  of  the  common  adhesive 

Elaster,  and  of  isinglass  plaster,  has  been  already  described 
see  Part  I.) :  aided  by  a  proper  position  of  the  injured  part, 
the  strips  will  be  found  adequate  to  secure  the  adhesion  of 
most  wounds.  When  the  extent  of  surface  upon  which  the 
strips  can  be  applied  is  not  sufficiently  great  to  ensure  firm 
support,  their  power  may  be  much  increased  by  placing  a 
narrow  strip  of  plaster  near  to,  and  parallel  with,  each  edge 
of  the  wound,  and  crossing  the  main  strips  upon  them. 
Again,  if  the  strips  are  subjected  to  much  strain,  it  will  be 
found  of  importance  to  make  moderate  pressure  upon  the 
muscles  by  means  of  a  roller,  or  bandage  of  Scultetus.  In 
removing  this  dressing,  the  precautions  advised  in  the  first 
part  of  this  volume  should  be  attended  to. 

From  his  own  experience,  the  author  ventures  to  think  that 
the  reports  with  regard  to  the  irritation  caused  by  the  ordi- 
nary adhesive  plaster  of  good  quality,  and  the  liability  of 
erysipelas  being  occasioned  by  it,  are  very  much  exaggerated. 
Recently  it  has  been  ascertained  that  "  collodion"  a  solu- 
tion in  ether  of  the  "gun-cotton,"  as  commonly  prepared,  is 
possessed  of  very  strong  adhesive  properties ;  it  may  be  spread 
upon  linen  or  silk,  and  then  applied  to  the  surface ;  and  it 
offers  this  advantage  over  other  adhesive  matter,  viz.:  that, 
being  insoluble  in  water,  the  parts  surrounding  the  wound 
may  be  washed  without  disturbing  the  wound  itself,  by  re- 
moving the  plaster  which  covers  it.  To  separate  the  plaster 
from  the  surface,  it  is  necessary  to  moisten  the  application 
with  ether.  (See  p.  38.) 

Gun-cotton  is  made  by  saturating  carded  cotton  in  a  mix- 
ture of  equal  parts  of  strong  nitric  and  sulphuric  acids,  then 
washing  the  cotton  in  water,  and  drying  it  at  a  temperature 
of  150°,  or  less. 

2.  Several  kinds  of  suture  have  been  invented  for  the  pur- 
pose of  securing  perfect  apposition  of  the  surfaces  of  incised 
wounds.     They  are  passed  directly  through  the  skin  at  the 
edges  of  the  wound,  or  through  strips  of  adhesive  plaster  pre- 


DRESSING    OF    WOUNDS.  305 

viously  applied  near  to  its  margins :  to  the  former,  the  term 
"wet  suture"  has  been  given,  the  latter  is  called  "the  dry 
suture."  Of  the  first  there  are  four  varieties  in  common  use: 
the  interrupted,  the  continued,  tho  quilled,  and  the  twisted 
suture. 

The  interrupted  suture  is  made,  by  passing  a  needle  armed 
with  a  single  strand  of  saddlers'  silk,  or  of  some  other  equally 
strong  material,  through  the  skin  from  without  inwards,  en- 
tering at  the  distance  of  two  or  three  lines  from  the  edge  of 
wound,  crossing  the  latter,  and  re-entering  the  skin  at  the 
opposite  margin  of  the  wound,  to  re-appear  a  few  lines  from 
the  edge :  the  two  portions  of  the  thread  are  then  tied  toge- 
ther in  the  sailors'  knot,  as  shown  in  fig.  144.  The  number 
of  sutures  thus  made  varies  with  the  length  of  the  wound  and 
the  strain  which  must  fall  upon  each  knot ;  generally,  their 
number  should  not  be  greater  than  may  be  necessary  to  re- 
tain the  lips  of  the  wound  in  close  apposition.  In  order  to 
diminish  the  number  of  sutures,  by  supporting  each  one,  strips 
of  adhesive  plaster  may  be  laid  across  the  wound,  between 
each  two  sutures,  leaving  space  enough  between  the  latter 
and  the  edges  of  the  plaster,  to  allow  of  the  escape  of  fluids 
from  beneath.  Additional  aid  is  sometimes  given  to  the 
stitch  by  a  roller,  or  a  bandage  of  Scultetus,  passed  around 
the  wounded  part ;  but  this  should  be  avoided  whenever  it  is 
practicable  to  do  so,  as  the  dressing  is  thereby  rendered  less 
light  and  cool. 

In  most  cases,  the  surfaces  of  the  wound  will  have  become 
sufficiently  adherent,  after  the  lapse  of  forty-eight  hours,  to 
admit  of  the  withdrawal  of  the  sutures  ;  this  may  be  effected 
by  passing  the  sharp  point  of  a  pair  of  narrow-bladed  scissors 
beneath  the  thread  and  cutting  it,  after  which  it  may  be 
gently  drawn  out.  If  allowed  to  remain  longer  than  two  or 
three  days  in  the  skin,  the  suture  excites  inflammation  and 
slight  ulceration  around  itself,  thereby  deforming  the  appear- 
ance of  the  cicatrix.  The  strips  of  adhesive  plaster  and,  if 
necessary,  the  bandage  also,  should  be  retained,  in  order  to 
give  security  to  the  recently  formed  adhesions,  after  the  re- 
moval of  the  suture.  The  following  drawing  illustrates 
the  application  of  the  interrupted  suture.  (Fig.  149.) 

The  continued  suture  is  less  used  than  the  last.     It  is  the 
one  employed  in  wounds  of  the  intestines,  and  also  in  closing 
26* 


306  DRESSING    OF    WOUNDS. 

the  incisions  made  in  conducting  post-mortem  examinations. 

It  is  the  stitch  commonly  used  in 
sewing,  and  is  otherwise  called 
the  glover  s  stitch.  The  needle 
is  first  entered  as  in  making  the 
interrupted  suture ;  it  then  crosses 
the  wound  obliquely  from  the  op- 
posite side  to  the  margin  first 
penetrated,  and  is  again  inserted 
at  a  point  helow  the  first,  thus 
crossing  and  recrossing  the  wound 
ohliquely  until  a  sufficient  num- 
ber of  stitches  have  been  laid, 
ff?  when  the  ends  of  the  thread  are 

secured,  at  each  extremity  of  the 
wound,  by  being  tied  around  the 

first  and  last  stitch  respectively.  The  distance  between  the 
stitches  must  depend  upon  the  length  of  the  wound  and  the 
resistance  which  they  are  expected  to  overcome  ;  they  may 
be  aided  in  their  retentive  action  by  the  application  of  a  roller, 
or  a  bandage  of  Scultetus. 

The  quilled  suture  is  now  but  little  used :  Mr.  Liston  says 
of  it,  "  it  is  only  employed  in  one  operation  —  that  for  lace- 
rated perinseum.  I  have  used  it  two  or  three  times  in  cases 
of  this  kind."  It  is  effected  by  entering  the  needle,  armed  as 
before,  at  about  four  lines  from  the  edge  of  the  wound,  and 
carrying  it  downwards  to  reappear  at  the  bottom  of  the 
wound ;  then  ascending  just  exterior  to  the  opposite  lip,  it 
emerges  at  about  four  lines  from  the  edge,  opposite  the  point 
at  which  it  first  entered ;  if  the  wound  be  very  deep,  it  will 
be  more  convenient  to  carry  the  needle  from  above  downwards, 
on  both  sides,  rather  than  from  the  bottom  of  the  wound  to- 
wards the  surface.  A  portion  of  the  thread  should  be  left 
extending  from  each  side  of  the  incision,  and  when  a  sufficient 
number  of  stitches  have  been  introduced  to  support  the  wound, 
a  piece  of  a  gum-elastic  bougie,  or  a  quill,  of  the  same  length 
as  the  latter,  is  placed  parallel  with  the  incision  on  each  side, 
between  each  two  strands,  which  are  then  tied  upon  the  tube 
with  force  sufficient  to  retain  the  entire  surfaces  of  the  wound 
in  apposition,  after  they  have  been  approximated  by  the  hands. 
(Fig.  150.) 


DRESSING     OF    WOUNDS. 


SOT 


The  advantages  of  FlG- 15°- 

this  suture  are,  that 
it  forces  the  sides  of 
the   wound   together 
throughout  its  entire 
depth,  instead  of  the 
edges     merely,    and 
that,  by  the  interven- 
tion of  the  quills,  or  pieces  of  bougie,  there  is  less  danger  of 
the  skin  being  torn  by  the  threads  at  the  points  of  puncture. 
A  bandage  may  be  employed  as  an  additional  support. 

The  needle  used  in  these  varieties  of  suture  is  commonly 
called  the  surgeon  s  needle :  it  is  more  or  less  curved,  accord 
ing  to  the  fancy  of  the  operator,  and  has  a  double  cutting 
edge  extending  about  half  of  its  length  from  the  point,  which 
should  be  very  sharp  ;  the 
eye  should  be  large.    The  FIG.  151. 

accompanying  drawing  re- 
presents two  forms  of  the 
surgeon's  needle,  of  which 
the  straightest  will  gene- 
rally be  found  to  be  the 
most  convenient  (fig.  151) : 
the  size  should  correspond 
with  the  thickness  of  the 
thread  to  be  used,  and  the  part  or  character  of  the  wound, 
for  which  it  is  to  be  employed. 

The  twisted  suture  is  chiefly  used  to  promote  adhesion  be- 
tween the  edges  of  incised  wounds  upon  the  face,  especially 
after  the  operation  for  the  relief  of  hare-lip.  A  well-silvered 
pin,  very  sharp  at  the  point,  is  passed,  with  a  rotatory  motion, 
through  the  skin,  at  a  point  two  or  three  lines  distant  from 
the  edge  of  the  incision,  and  brought  out  on  the  opposite  side, 
at  the  same  distance,  the  extremities  of  the  pin  extending  be- 
yond the  incision ;  then  the  centre  of  a  single  strand  of 
thread  or  silk,  is  thrown  over  one  end  of  the  pin,  and  crossing 
the  wound — of  which  the  lips  are  now  in  contact, — is  turned 
around  the  other  extremity  of  the  pin,  in  the  form  of  the 
figure  8  ;  thus  the  threads  cross  and  recross  until  several  turns 
are  made.  Generally,  two  pins  are  introduced,  sometimes 


308 


DRESSING    OF    WOUNDS. 


FIG.  153. 


FIG.  152.  more,  and  thread   twisted   upon   each,  as 

,1.  above.     (Fig.  152.)     When  the  suture  is 

thus  made,  the  extremities  of  the  pins  are 
cut  off  by  means  of  a  pair  of  small  cutting- 
pliers.  The  pins  themselves  should  be 
carefully  drawn  out  at  the  expiration  of  two, 
or  at  most,  three  days,  otherwise  ulceration 
will  be  excited  around  them,  and  an  un- 
pleasant scar  will  be  the  result ;  the  threads  should  not  be 
disturbed  for  some  days  longer.  When  used  in  an  operation 
upon  the  upper  lip,  the  invaginated  bandage,  shown  in  fig.  25, 
will  be  found  a  convenient  support,  if  any  should  be  needed. 

Mr.  Fergusson  is  in  the 
habit  of  employing  the 
instrument  represented  in 
fig.  153,  for  this  purpose. 
It  consists  of  a  semi- 
circular spring,  padded  at 
both  extremities,  which 
passes  around  the  base 
of  the  cranium,  so  that 
the  pads  cause  the  mar- 
gins of  the  wound  to  ap- 
proximate, and  thus  re- 
move any  strain  from  the 
sutures.  The  instrument 
is  held  in  position  by 
straps. 

A  particular  kind  of 
needle  or  pin,  made  of 
silver,  with  a  steel  point 
which  may  be  detached, 
has  been  contrived  for 
this  suture,  but  the  common  pin  of  good  quality  answers  just 
as  well,  and  is  much  more  convenient. 

The  dry  suture,  as  before  hinted,  is  made  by  surrounding 
the  part — a  limb  generally — with  a  strip  of  adhesive  plaster 
placed  close  to  each  margin  of  the  wound,  and  passing  from 
one  to  the  other  as  many  stitches  of  the  interrupted  suture  as 
may  be  required  to  retain  the  edges  in  apposition. 

M.  Baudens,  chief  surgeon  to  the  "  Val  de  Grace"  hospital, 


DRESSING    OF    WOUNDS.  309 

recommends  the  following  kind  of  dry  suture,  to  approximate 
the  edges  of  the  flap  after  amputation  ;  he  surrounds  the  limb, 
above  its  cut  extremity,  with  a  circular  bandage,  through 
which  he  passes  pins  in  front  and  behind,  leaving  the  extremi- 
ties of  the  pins  projecting ;  then,  while  the  flaps  are  brought 
together  accurately  by  an  assistant,  the  surgeon  passes  from 
one  pin  to  the  opposite,  pieces  of  thread,  wrapping  them 
around  the  pins  with  sufficient  tightness  to  retain  the  flaps  in 
apposition. 

M.  Vidal  (de  Cassis)  has  invented  an  ingenious  little  con- 
trivance for  retaining  the  margins  of  incised  wounds  in  appo- 
sition. He  calls  it  the  "  Serre-fine"  and  the  Institute  of 
France  awarded  him  a  prize  for  it.  It  is  made  of  fine  silver- 
wire,  twisted  so  as  to  bear  a  remote  resemblance,  in  shape  and 
size,  to  the  "  eye"  which  ladies  use  in  hooking  their  dresses ; 
the  end  of  each  leg  is  bent  at  a  right-angle,  and  is  toothed, 
so  as  to  be  capable  of  piercing  and  remaining  fixed  in  the 
skin ;  and  the  spring  is  so  arranged  that  when  the  "  serre- 
fine"  is  left  to  itself,  after  having  been  properly  set  in  the 
margins  of  the  incision,  it  approximates  these. 

M.  Yidal  has  described  and  represented  this  little  invention 
in  the  last  edition  of  his  "  Traite  de  Pathologie  Externe" 

We  think  it  rather  ingenious  and  pretty,  than  useful. 

The  bandages  used  to  promote  union  of  incised  wounds  are 
the  common  roller,  the  bandage  of  Scultetus,  and  the  invagi- 
nated  bandage.  The  first  two  are  employed  to  give  support 
merely  to  adhesive  strips  and  sutures.  The  invaginated 
bandage  acts  directly  by  approximating  the  edges  of  the  in- 
cision ;  its  composition  and  mode  of  application  vary,  as  the 
wound  is  longitudinal  or  transverse.  These  bandages  are 
applied  to  the  extremities  generally. 

The  invaginated  bandage  for  longitudinal  wounds  is  thus 
prepared  :  A  linen  roller  is  taken,  of  a  width  corresponding 
with  the  length  of  the  wound,  and  sufficiently  long  to  make 
several  turns  around  the  limb :  at  the  free  extremity  of  this 
roller  several  slits  are  made,  each  about  an  inch  broad  and 
six  or  eight  inches  long ;  and  beyond  these,  at  the  distance 
of  a  few  inches,  fenestrae  are  cut,  in  number  corresponding 
with  the  slits,  (fig.  154.)  Thus  prepared,  the  centre  of  the 
undivided  portion  of  the  bandage  is  placed  directly  opposite 
the  wound,  by  the  margins  of  which  graduated  compresses 


310 


DRESSING    OF    WOUNDS. 


(a,  a,  fig.  155)  have  been  arranged,  one  on  each  side :  the 
slits,  £>,  b,  6,  are  passed  through  the  corresponding  fenestrse, 
£,  c,  (?,  and  these  two  portions  of  the  roller  drawn  in  opposite 
directions  until  the  edges  of  the  wound  are  in  apposition ; 
(fig.  155.)  Then  the  slits  are  laid  flatly  upon  the  surface, 


FIG.  154. 


FIG.  155. 


and  the  bandage  is  completed  by  circular  turns  of  the  roller. 
The  efficacy  of  this  uniting  bandage  is  much  increased  by  the 
employment  of  the  compresses,  which  act  very  much  as  the 
quilled  suture,  by  pressing  together  the  entire  depth  of  the 
sides  of  the  wound.  It  will  be  found  an  advantageous  mode 
of  approximating  the  surfaces  of  deep  incisions  of  the  thighs, 
particularly. 

The  invaginated  bandage  for  transverse  wounds. 

COMPOSITION.  —  A  piece  of  linen  from  two  to  three  feet 
long,  corresponding  in  breadth  with  the  length  of  the  wound, 
and  divided  at  one  extremity  into  two  or  more  slits,  each 
about  an  inch  wide  and  six  inches  or  more  in  length,  to  cor- 
respond with  the  same  number  of  fenestrge  made  in  a  second 
piece  of  linen  of  the  same  dimensions  as  the  first ;  two  rollers, 
each  six  yards  long  and  two  and  a  half  inches  wide ;  together 
with  two  graduated  compresses. 

APPLICATION. — The  limb  having  been  placed  in  a  position 
most  favourable  for  relaxing  the  divided  muscles,  the  surgeon 
makes  a  few  turns  of  one  roller,  6,  around  the  limb  below  the 
wound,  and  upon  these  lays  the  fenestrated  bandage,  so  that 
the  divided  portion  stretches  upon  and  across  the  incision, 
while  the  other  part  rests  upon  the  limb  below  the  wound. 


DRESSING    OF    WOUNDS. 


311 


FIG.  156. 


The  extremity  of  this  portion  is  reflected  upwards  over  the 
turns  of  the  roller,  which  is  now  resumed  and  made  to  secure 
the  bandage  in  position. 
The  other  band  is  now 
confined  upon  the  limb 
above  the  wound,  in  the 
same  manner,  by  means 
of  the  second  roller, 
the  slits  corresponding 
in  position  with  the 
wound:  next  the  com- 
presses, <?,  c,  are  placed 
parallel  with  the  edges 

of  the  incision,  one  above,  and  the  other  below :  then  the  slits 
of  one  band  are  passed  through  the  fenestrse  of  the  other, 
(fig.  156.)  The  two  bands  are  drawn  in  opposite  directions, 
so  as  to  approximate  the  lips  of  the  wound,  and  are  firmly 
fixed  by  turns  of  the  rollers  passing  respectively  above  and 
below  the  seat  of  the  injury. 


CHAPTER  VI. 


OF  THE  INTRODUCTION  OF  THE  CATHETER. 


FIG.  157. 


A  CATHETER,  in  its  most  general  signification,  is  an  open 
tube,  made  usually  of  silver,  or  of  gum-elastic  prepared  in 
a  peculiar  manner,  to  which  such  a  form  and  firmness  are 

given  as  permit  of  its  intro- 
duction into  the  various  canals 
of  the  body.  The  passages 
into  which  such  an  instrument 
is  usually  inserted  are  the 
lachrymal  tube,  the  eustachian 
tube,  the  oesophagus,  the 
urethra,  and  the  large  intestine. 
1.  Catheterism,  or  rather 
dilatation,  of  the  lachrymal 
passages,  is  sometimes  prac- 
tised for  the  purpose  of  re- 
moving obstructions  to  the 
escape  of  the  tears  along  their 
proper  excretory  passages. 
Before  resorting  to  this  opera- 
tion, however,  it  is  important 
to  determine  if  the  difficulty  may  not  be  an  Epiphora,  an  ex- 
cessive secretion,  rather  than  a  Stillicidium. 

It  is  also  essential  to  bear  in  mind  the  natural  direction  of 
the  lachrymal  passages,  as  represented  in  fig.  157,  for  it  is 
along  these  same  tortuous  channels  that  the  dilating  instru- 
ment must  pass. 

If  the  puncta  lachrymalia  be  occluded,  their  minute  ori- 
fices may  first  be  opened  by  the  point  of  a  pin,  and  then  one 
of  Anel's  gold  probes  (fig.  158)  may  be  introduced,  or  one  of 
the  less  expensive  instruments  of  which  we  shall  presently 
speak ;  the  size  of  the  dilator  should  be  gradually  increased, 
until  a  permanent  cure  of  the  stricture  has  been  gained. 

(312) 


INTRODUCTION  OF  THE  CATHETEK.    313 

It  may  be   that  the   lachrymal  canals,  leading  from  the 

puncta  to  the  sac,  are  narrowed,  in 
FIG.  158.  which  case  the  same  instrument  should  FIG.  159. 
be  passed  along  these  passages.  To 
dilate  the  superior  canal,  the  probe  must 
be  passed  almost  perpendicularly  up- 
wards, inclining  a  little  outwards,  then 
obliquely  inwards  and  downwards.  In 
operating  on  the  lower  canal,  pass  the 
probe  downwards,  then  obliquely  inwards 
and  upwards. 

The  Nasal  duct,  running  from  the 
lachrymal  sac  to  the  inferior  rneatus  of 
the  nostril,  opening  below  the  inferior 
turbinated  bone,  may  be  diminished  in 
its  calibre,  and  thereby  occasion  stillici- 
dium  lachryrnarum.  To  overcome  this 
obstruction,  various  methods  have  been 
adopted  ;  the  most  feasible  is  probably  that  by  dila- 
tation. A  series  of  silver  probes  should  be  prepared, 
four  or  five  inches  long,  varying  in  size  from  that  of 
the  No.  17  wire  to  No.  21,  slightly  bent,  as  the  one 
illustrated  in  fig.  159,  or  straight,  if  preferred ;  one 
extremity  may  be  turned  as  in  the  figure,  the  other 
should  be  slightly  pointed,  but  not  sharp,  to  enter  the 
puncture.  In  treating  stricture  of  the  nasal  duct,  it 
is  most  convenient  to  pass  the  probe  through  the  in- 
ferior canal,  in  the  manner  already  explained ;  and 
when  it  has  reached  the  sac,  the  instrument  should 
be  pointed  almost  vertically  downwards  until  it  has 
gained  the  inferior  meatus  of  the  nose,  which  may  be 
ascertained  readily  by  passing  a  probe  into  the  ante- 
rior naris  of  the  side  operated  upon,  and  touching  the  one 
which  has  been  inserted  from  above.  A  small  sized  instru- 
ment should  be  first  used,  and  after  having  been  introduced, 
should  be  allowed  to  remain  a  few  hours,  unless  much  pain  be 
occasioned  thereby ;  and  at  intervals  of  four  or  five  days,  the 
same  or  a  larger  probe  should  be  passed,  the  size  being  gra- 
dually increased  until  the  stricture  is  cured.  After  each  in- 
troduction, it  is  well  to  apply  warm  water  with  laudanum,  to 
allay  any  irritation  which  may  have  been  caused.  It  is  im- 
27 


314    INTRODUCTION  OF  THE  CATHETER. 

portant  to  avoid  any  haste,  both  in  the  passage  of  the  probe 
at  each  sitting,  and  in  increasing  the  size  of  the  instrument, 
in  order  to  guard  against  the  production  of  inflammation. 

Mr.  Morgan  has  recommended  dilatation  of  the  nasal  duct 
from  below,  by  introducing  a  probe,  such  as  is  represented  in 
fig.  160,  beneath  the  inferior  turbinated  bone  into  the  lower 
orifice  of  the  duct.  This  method  is  less  generally  practised 
than  the  other,  though  highly  spoken  of  by  Mr.  Morgan. 
(Lectures  on  the  Diseases  of  the  Eye.) 

FIG.  160. 


Anel  advised  the  syringing  of  the  duct  with  astringent 
solutions.  To  accomplish  this,  a  fine  tube  must  first  be  passed 
into  the  duct  from  the  punctum  lachrymale,  and  the  nozzle  of 
the  small  syringe  of  Anel  be  fitted  into  its  upper  orifice ; 
when  the  piston  of  the  syringe  is  being  depressed,  the  other 
punctum  must  be  closed  by  pressure  of  the  finger,  otherwise, 
the  fluid  will  pass  out  of  it  from  the  lachrymal  sac.  Not 
much  can  be  effected  in  this  way,  however,  the  tube 
being  too  fine  to  permit  any  force  of  injection.  Syringing 
of  the  duct  in  this  manner,  after  the  use  of  the  probe,  may 
assist  the  operation  of  the  latter,  and  is  useful  also  in  freeing 
the  passage  from  mucus. 

It  should  be  borne  in  mind,  that  very  much  can  be  done 
for  the  cure  of  stillicidium,  by  correcting  any  temporary  con- 
gestion or  inflammation ;  frequently,  indeed,  this  affection 
may  be  cured  without  resorting  to  such  mechanical  means  as 
we  have  described. 

For  farther  details  concerning  these  operations,  and  espe- 
cially for  proper  views  concerning  the  pathology  of  still  ici- 
dium,  we  refer  our  readers  to  Treatises  on  Diseases  of  the 
Eye,  among  the  best  of  which  is  the  American  Edition  of 

r.  Lawrence's  book,  by  Dr.  Hays. 


INTRODUCTION  OF  THE  CATHETER. 


315 


2.  CATHETERISM  OF  THE  EUSTACHIAN  TUBE. 

The  catheter  used  in  this  operation  is  gene- 
rally of  silver,  about  six  inches  long,  slightly 
curved  at  the  end  which  enters  the  tube,  and 
gradually  increasing  in  size  from  this  to  the 
other  extremity.  It  is  open  at  both  ends,  and 
it  is  of  very  great  importance,  that  the  ex- 
tremity which  is  intended  to  be  passed  into  the 
canal,  shall  be  well  rounded ;  otherwise,  con- 
siderable irritation,  and  even  excoriation  of  the 
lining  membrane  of  the  tube,  will  be  produced. 
The  catheter  which  Mr.  Wilde,  of  Dublin,  one 
of  the  most  dexterous  operators  and  one  of  the 
best  authorities,  prefers,  is  represented  in  fig. 
161 ;  it  is  here  shown  in  its  actual  dimensions. 
The  ring  at  the  larger  extremity  of  the  catheter 
should  be  in  the  same  plane  as  the  beak  of  the 
instrument,  in  order  that  while  the  latter  is 
being  introduced,  the  operator,  by  looking  at 
the  ring,  may  know  the  direction  of  the  beak. 

It  will  be  recollected  that  the  pharyngeal 
orifice  of  the  eustachian  tube  is,  according  to 
Malgaigne,  situated  at  the  distance  of  two 
inches  and  a  few  lines  from  the  anterior  orifice 
of  the  nostril  of  the  same  side,  on  a  line  with 
the  external  wall  of  the  meatus  inferior,  and 
about  half  way  between  the  floor  of  the  nostril 
and  the  inferior  spongy  bone. 

To  reach  this  point  with  the  catheter,  the 
following  plan,  recommended  by  M.  Gairal,  is 
probably  the  best :  —  The  patient  being  seated 
on  a  chair,  with  his  head  thrown  a  little  back- 
wards and  supported  upon  a  pillow,  the  sur- 
geon stands  in  front  of  him  and  glides  the  point 
of  the  catheter,  the  instrument  having  been 
oiled,  along  the  floor  of  the  nostril  of  the  same 
side,  towards  the  soft  palate :  the  convexity  of 
the  instrument  should  be  directed  inwards  and 
upwards,  its  concavity  downwards  and  out- 
wards. ^  When  the  point  has  reached  the  velum 
palati,  which  will  be  indicated  by  a  movement 
of  deglutition,  the  shaft  of  the  catheter  should 


Fro.  161. 


316        INTRODUCTION    OF    THE    CATHETER. 

be  rotated  through  a  quarter  of  a  circle,  so  as  to  turn  the 
point  outwards  and  upwards  to  the  same  extent,  and  at  the 
same  time  pushed  backwards  for  a  few  lines,  when  it  will 
have  entered  the  expanded  orifice  of  the  tube.  (Malgaigne's 
Operative  Surgery,  Brittan's  translation,  p.  314,  315  — 
London,  1846.) 

Some  surgeons  prefer  a  catheter  made  of  gum-elastic,  with 
a  stilet,  so  that,  when  the  point  of  the  catheter  has  reached 
the  orifice  of  the  tube,  the  stilet  may  be  glided  into  the  latter,  • 
and  the  catheter  itself  slid  in  upon  it.  But  this  we  cannot 
but  regard  as  an  improper  instrument ;  for  the  operator  is  much 
more  liable  to  injure  the  delicate  lining  membrane  of  the  canal 
with  the  stilet ;  and  the  withdrawal  of  the  latter,  as  Mr. 
Wilde  remarks,  is  very  apt  to  cause  the  catheter  itself,  if  it 
have  entered  the  canal,  to  be  disadjusted. 

Generally,  the  simple  opening  of  the  tube  by  the  entrance 
of  the  instrument,  is  sufficient  to  remove  any  temporary  ob- 
struction which  may  have  impeded  the  free  access  of  air  to 
the  tympanum.  It  is  sometimes  necessary,  however,  to  resort 
to  injections  of  air  through  the  catheter :  this  should  be  done 
very  gently  and  cautiously.  To  accomplish  this  object,  it  is 
necessary  to  have  a  properly  contrived  air-press,  from  which 
the  air  may  be  injected,  and  it  is  also  essential  that  the  catheter 
shall  be  firmly  secured  to  the  head,  lest  it  slip  and  thereby 
mischief  be  done.  The  air  introduced  may  be  the  ordinary 
atmosphere,  or  it  may  be  some  medicated  vapour,  according 
to  the  supposed  condition  of  the  lining  membrane  of  the  tube. 
Eustachian  catheterism,  certainly,  when  associated  with  this 
farther  process,  does  not  properly  come  under  the  domain  of 
Minor  Surgery.  It  is  a  delicate  operation,  and  should  not  be 
carelessly  or  ignorantly  undertaken.  Before  attempting  it, 
more  minute  instruction  should  be  sought  than  we  pretend  to 
give.  We,  therefore,  refer  our  readers  to  the  special  treatises 
on  aural  diseases,  the  best  of  which,  we  think,  is  Mr.  Wilde's. 
3.  CATHETEBJSM  OP  THE  OESOPHAGUS. — The  object  of  this 
operation  is,  to  insert  a  tube  into  the  stomach,  for  the  pur- 
pose of  removing  fluids  from  this  organ,  or  of  introducing 
them  into  it.  The  catheter  used  is  of  gum-elastic,  of  a 
diameter  varying  to  suit  the  capacity  of  different  gullets,  from 
two  feet  to  two  and  a  half  feet  long,  and  furnished  with  a 
flexible  stilet  made  of  a  thin  strip  of  whalebone ;  the  extrem- 


INTRODUCTION    OF    THE    CATHETER.         317 

ity  which  enters  the  stomach  is  closed  and  rounded,  but  fluids 
reach  the  interior  of  the  tube,  and  escape  from  it,  through 
two  large  eyes,  placed  one  on  each  side,  near  this  end ;  the 
other  extremity  is  open  and  is  usually  somewhat  expanded,  to 
allow  of  the  easy  insertion  of  a  syringe-pipe. 

The  following  is  the  simplest  and  readiest  mode  of  intro- 
ducing the  instrument :  let  the  patient  be  seated,  if  possible, 
his  head  thrown  back  and  supported,  and  his  mouth  widely 
opened,  and  kept  open,  if  necessary,  by -a  piece  of  wood,  or 
something  similar;  then  the  surgeon,  taking  his  position  in 
front  of  the  patient,  guides  the  stomach-end  of  the  tube,  pre- 
viously oiled  and  having  the  stilet  in  its  cavity,  towards  the 
posterior  wall  of  the  pharynx ;  the  stilet  should  now  be  with- 
drawn, in  order  to  allow  the  tube  to  curve  more  readily  as  the 
surgeon  pushes  it  downwards  through  the  pharynx  and  oeso- 
phagus. If  the  patient  be  possessed  of  his  faculties,  and  his 
brain  be  in  a  condition  to  respond  to  impressions  made  upon 
sentient  surfaces,  the  tube  will  be  drawn  downwards  to  the 
oesophagus  by  the  contraction  of  the  pharyngeal  muscles,  as 
in  swallowing,  so  soon  as  the  point  of  the  instrument  comes 
within  the  sphere  of  their  action ;  the  surgeon  therefore  is  as- 
sisted in  the  performance  of  the  operation,  which  is  thus  made 
much  easier.  But  it  happens  very  often  that  the  patient  upon 
whom  the  operation  is  being  performed  has  stupified  himself, 
so  that  no  reflex  muscular  action  takes  place.  The  entrance 
of  the  tube  into  the  larynx  will  be  recognised  by  a  spasmodic 
cough,  or  by  the  rushing  of  the  air  through  the  canal  thus  in- 
troduced ;  the  mistake  should  at  once  be  rectified. 

Fluids  may  be  thrown  into  the  stomach  through  the  tube, 
by  means  of  a  common  syringe,  or  of  the  stomach-pump  pre- 
pared expressly  for  this  purpose.  The  first  is  the  most  sim- 
ple and  is  equally  effectual.  Care  should  be  exercised  that 
tKe  liquid  injected  be  of  a  proper  temperature. 

If  the  object  be  to  remove  liquid  matters  from  the  stomach, 
a  certain  amount  of  fluid  should  be  first  introduced,  either 
simple  tepid  water,  or  some  other  fluid  capable  of  neutralizing 
the  noxious  matter  which  may  have  been  swallowed ;  then  the 
whole  should  be  withdrawn  by  means  of  the  syringe,  and  the 
stomach  thoroughly  cleansed  by  repeated  injections  of  warm 
water,  or  mucilage. 

Patients  who  are  unable  to  swallow,  or  who  obstinately  re* 
27* 


318    INTRODUCTION  OF  THE  CATHETER. 

fuse  to  swallow,  food,  may  be  sustained  by  injections  of  nutri- 
tious fluids  into  the  stomach  through  the  stomach-tube. 

When  it  is  desirable  that  the  tube  shall  be  allowed  to  re- 
main in  the  stomach  for  any  length  of  time,  it  is  recommended 
to  be  introduced  by  the  nostril.  For  this  purpose,  a  tube  ra- 
ther smaller  is  preferable  than  if  the  other  method  be  selected  ; 
it  is  pushed  backwards  along  the  floor  of  the  nostril,  and  when 
it  has  reached  the  edge  of  the  velum,  the  stilet  is  withdrawn, 
and  the  flexion  of  the  extremity  of  the  tube  aided,  if  neces- 
sary, by  the  finger  carried  through  the  mouth.  This  method 
is  not  quite  so  easy  as  the  first. 

4.  CATHETERISM  OF  THE  URETHRA. — Very  often  the  uri- 
nary-bladder, both  of  the  male  and  female,  becomes  distended, 
being  deprived,  from  a  variety  of  causes,  of  its  natural  expul- 
sive power  over  its  contents;  in  such  circumstances,  it  becomes 
necessary  to  resort  to  some  artificial  means  of  relief.  In 
many  cases,  the  difficulty  may  be  overcome  by  employing  re- 
medies which  tend  to  relax  spasmodic  muscular  action,  such  as 
a  full  dose  of  opium  administered  by  the  mouth,  or  in  the  form 
of  a  small  enema  ; — or  an  enema  of  camphor  ;  or,  again,  a  hot 
bath  maybe  tried  ;  often,  too,  the  operation  of  a  full  purgative 
clyster  will  be  attended  with  evacuation  of  the  bladder.  But 
where  these  and  similar  means  fail,  it  is  requisite  to  introduce 
the  catheter  through  the  urethra  into  the  bladder  itself. 

CATIIETERISM  OF  THE  URETHRA  OF  THE  MALE. — The  in- 
strument used  for  this  operation  is  a  cylindrical  tube  made  of 
silver,  or  of  gum  elastic ;  it  should  be  about  nine  inches  long 
and  of  a  diameter  suited  to  that  of  the  urethra,  which  of  course 
varies  in  size  according  to  the  age  of  the  individual  and  to 
certain  morbid  conditions  of  the  canal ;  the  extremity  which 
enters  the  bladder  should  be  conical  in  shape,  closed  at  its 
point,  but  perforated  just  above  the  latter  with  two  or  more 
well-opened  eyes ;  a  moderate  degree  of  curvature  should  also 
be  given  to  this  part  of  the  catheter,  though  a  perfectly  straight 
instrument  may  be  passed  through  a  healthy  urethra ;  the 
other  extremity  of  the  tube  is  open,  and  generally  has  a  small 
ring  attached  to  each  side  of  it,  for  the  purpose  of  affording 
means  of  confining  the  instrument  in  the  bladder,  if  occasion 
require,  (fig.  162.)  The  double  catheter  represented  in  fig. 
3,  will  be  found  a  very  convenient  instrument.  When  the 


INTRODUCTION  OF  THE  CATHETER.    319 
FIG.  162. 


gum  elastic  catheter  is  used,  the  proper  curve  and  firmness 
are  given  to  it,  by  bending  the  iron  wire  inserted  in  its  cavity. 

The  following  will  be  found  the  most  convenient  method  of 
introducing  the  catheter,  in  most  cases :  The  patient  should 
lie  upon  his  back,  or  be  a  little  inclined  towards  the  right  side, 
his  thighs  semi-flexed  and  separated,  and  his  back  slightly 
raised  in  order  to  relax  the  muscles  which  would,  otherwise, 
somewhat  constrict  the  canal ;  the  surgeon  places  himself  on 
the  left  side  of  the  patient,  and  exposes  the  head  of  the  penis 
with  the  thumb  and  fore  and  middle  fingers  of  the  left  hand, 
at  the  same  time  making  slight  compression  upon  the  glans 
penis  so  as  to  open  the  extremity  of  the  urethra :  he  holds  the 
open  end  of  the  catheter,  previously  warmed  and  oiled,  in  his 
right  hand,  between  the  thumb  and  the  fore  and  middle  fin- 
gers, the  concavity  of  the  instrument  looking  downwards,  and 
engages  its  point  in  the  orifice  of  the  canal,  the  direction  of 
the  tube  corresponding  with  the  line  of  flexure  of  the  groin  ; 
(fig.  163.)  With  a  moderate  degree  of  force,  the  instrument, 
still  in  this  line  of  direction,  is  pressed  onwards  through  the 
canal  until  its  point  reaches  the  membranous  portion  of  the 
urethra  beneath  the  arch  of  the  pubis,  when  the  right  hand  of 
the  surgeon,  and  with  it  the  catheter,  is  gradually  raised  and 
at  the  same  time  carried  towards  the  middle  line  of  the  abdo- 
men, after  which  it  should  be  thrown  downwards  more  and 
more  between  the  thighs ;  its  passage  through  the  circle  of  the 
sphincter  muscle  at  the  neck  of  the  bladder  will  be  indicated, 
generally,  by  a  slight  shiver,  or  tremor,  or  a  sensation  of  nau- 
sea, on  the  part  of  the  patient,  and  its  entrance  into  the  blad- 
der itself  by  the  escape  of  urine  through  it ;  this  should  be 
prevented  by  the  application  of  the  thumb  upon  the  open  end 
of  the  catheter. 

With  practice,  the  instrument  may  be  introduced  into  the 
bladder,  if  the  urethra  be  in  a  healthy  condition,  without 


320    INTRODUCTION  OF  THE  CATHETER, 

FIG.  163. 


touching  the  penis  at  all  with  the  hand,  after  the  point  of 
the  catheter  has  entered  the  orifice  of  the  canal ;  and  this 
will  be  found  to  be  the  least  painful  method  to  the  patient, 
as  well  as  the  one  perhaps  least  liable  to  obstacles,  for  the 
instrument  will  glide  along  through  the  urethra  without 
being  deviated  by  any  forced  position  of  the  penis.  In 
either  method,  an  instrument  of  as  large  a  diameter  as  the 
urethra  will  admit  will  be  more  easily  introduced  than  a 
small  one. 

Some  of  the  French  surgeons  are  fond  of  practising  the 
"tour  de  maitre,"  as  it  is  called,  and  this  will  sometimes 
answer  when  the  more  common  method  has  failed.  The 
patient  may  either  stand,  or  lie  down,  or  occupy  a  sitting 
posture ;  the  surgeon  stations  himself  on  the  right  side,  and 
carries  the  instrument  down  the  urethra  to  the  arch  of  the 
pubis,  with  the  concavity  looking  downwards ;  when  it 
has  reached  this  point,  he  gives  it  a  turn  of  a  half  circle,  so 
as  to  bring  it  parallel  with  the  middle  line  of  the  body,  the 


INTRODUCTION    OF    THE    CATHETER.          321 

concavity  looking  upwards ;  this  movement,  conjoined  with 
a  little  pressure,  generally  causes  the  instrument  to  enter  the 
bladder. 

Even  in  perfectly  healthy  urethras,  the  catheter  often 
meets  with  impediments  to  its  course  along  the  canal,  but 
these  are  readily  obviated.  Thus  the  point  of  the  instru- 
ment may  come  in  contact  with  the  front  of  the  pubis, 
owing  generally  to  slight  deviation  of  the  position  of  the 
penis,  or  to  too  great  pressure  against  the  superior  surface 
of  the  urethra  from  the  point  of  the  catheter.  Again,  when 
the  tube  has  come  within  the  action  of  the  muscles  which 
compress  the  membranous  portion  of  the  canal,  and,  still 
more,  when  it  has  reached  the  neck  of  the  bladder,  its  farther 
advance  will  be  often  checked  by  the  contraction  of  the  mus- 
cular fibres  at  these  points ;  but  a  little  patience  on  the  part 
of  the  surgeon  is  all  that  is  required  to  overcome  this  momen- 
tary obstacle. 

When  the  cause  of  the  obstruction  is  an  organic  alteration 
of  the  urethra,  or  of  the  parts  connected  with  it,  much  more 
difficulty  is  experienced  in  the  introduction  of  the  catheter. 
The  most  common  sources  of  embarrassment  of  this  kind  are 
stricture  and  enlargement  of  the  prostate  gland. 

If  there  be  a  stricture  of  the  urethra,  the  size  of  the  ca- 
theter must  be  adapted  to  the  diminished  calibre  of  the  canal ; 
it  is  necessary,  therefore,  to  have  a  number  of  catheters  of 
different  sizes  always  at  one's  command.  The  resort  to  much 
force  in  introducing  the  instrument  should  be  avoided,  parti- 
cularly when  the  stricture  is  within  the  pubic  portion  of  the 
canal,  as  a  false  passage  may  be  made  more  easily  at  this 
portion  than  in  advance  of  it.  The  operation  maybe  assisted 
by  drawing  the  urethra  over  the  catheter ;  by  first  using  a 
large  instrument,  until  the  stricture  is  reached,  and  then 
drawing  the  penis  over  it,  so  as  to  make  an  entrance  fully 
into  the  strictured  part,  then  taking  a  smaller  instrument 
with  a  resort  to  the  same  manipulation.  The  use  of  the 
warm-bath,  the  application  of  warm  fomentations  to  the  peri- 
neum, or  the  administration  of  anodyne  enemata,  or  inducing 
anesthesia  by  inhalations  of  ether  or  chloroform,  will  usually 
assist  the  operation,  by  relaxing  the  muscles  which  directly 
or  indirectly  constrict  the  urethra.  In  the  London  Lancet, 
for  1851,  Mr.  Thomas  Wakley  describes  a  method  of  effecting 


322    INTRODUCTION  OF  THE  CATHETER. 

prompt  dilatation  of  the  urethra  which  may  prove  very  ser- 
viceable in  affording  relief  to  persons  suffering  from  retention 
of  urine,  with  stricture.  He  employs  a  series  of  instruments. 
He  first  introduces  a  very  fine  bougie,  and  upon  this,  as  on  a 
director,  a  small  catheter,  and  so  on,  gradually  increasing  the 
size  of  the  catheter,  until  one  of  sufficient  dimensions  has  been 
passed. 

M.  Amussat  frequently  resorts  to  forced  injections  of  the 
urethra,  to  relieve  retention  caused  by  stricture.  He  intro- 
duces a  catheter  of  gum-elastic,  open  at  both  ends,  as  far 
as  the  stricture,  and  then,  by  means  of  a  syringe,  forces  a 
stream  of  warm  water  along  the  urethra ;  this  removes  any 
mucus  which  may  have  collected,  and  dilates  the  canal  some- 
what, so  that  the  patient  can  generally  pass  a  small  quantity 
of  urine. 

One  of  the  most  common  causes  of  difficulty  in  the  intro- 
duction of  the  catheter,  particularly  in  old  men,  is  an  abnor- 
mal development  of  the  prostate  gland.  The  middle  lobe 
becomes  enlarged,  sometimes  to  a  very  great  degree,  and 
encroaches,  proportionally  to  its  size,  upon  the  canal  at  the 
neck  of  the  bladder,  thereby  opposing  a  mechanical  obstacle 
to  the  ingress  of  the  instrument.  (Fig.  164.)  There  are 

FIG.  164. 


several  expedients  by  which  this  difficulty  may  generally  be 
remedied.  If  the  gland  be  not  very  large,  a  silver  catheter 
may  usually  be  passed,  by  pressing  the  external  end  of  the 
instrument  well  downwards,  when  the  point  has  reached  the 


INTRODUCTION  OF  THE  CATHETER.    323 

prostate ;  or  a  gum-elastic  catheter  may  be  introduced  by 
withdrawing  the  stilet  a  little,  when  the  prostatic  part  of  the 
urethra  has  been  attained,  and  pushing  the  tube  onwards  with 
moderate  force  and  cautiously ;  the  point  of  the  instrument, 
meeting  with  the  obstacle,  will  yield  to  it  in  virtue  of  the 
flexibility  of  the  gum,  and  will  be  thrown  upwards  so  as  to 
clear  the  obstruction.  If  these  methods  fail,  the  surgeon 
should  insert  the  forefinger  of  his  left  hand,  previously  oiled, 
into  the  rectum,  and  press  the  point  of  the  catheter  upwards 
towards  the  pubis :  if  the  gland  is  very  large,  the  patient 
should  assume  the  erect  position,  or  he  may  bend  his  body 
forwards,  supporting  his  hands  against  the  back  of  a  chair  or 
a  table,  so  that  the  mere  weight  of  the  prostate  will  open  the 
neck  of  the  bladder  to  the  passage  of  the  instrument.  In 
cases  of  obstruction  from  this  cause,  the  curve  of  the  catheter 
should  be  somewhat  increased,  especially  near  its  point,  so 
that  it  will  pass  over,  and  in  advance  of,  the  enlarged  gland, 
instead  of  impinging  directly  against  it,  as  would  probably  be 
the  case  were  the  degree  of  curvature  smaller. 

Many  persons  suffer  very  much  from  the  performance  of 
this  operation,  even  where  there  is  no  stricture ;  others,  again, 
experience  severe  rigors,  or  fainting-fits.  If  these  peculiari- 
ties be  known  to  exist,  it  is  better,  unless  contra-indicated,  to 
put  the  patient  under  the  influence  of  ether,  or  to  diminish 
their  sensibility  by  opium  ;  and  if  such  effects  follow  the  ope- 
ration, morphia  should  be  given  to  allay  them.  And  in  all 
difficult  or  protracted  cases,  the  same  expedients  may  be  re- 
sorted to  with  great  advantage. 

Where  much  difficulty  is  experienced  in  introducing  the 
catheter,  or  in  the  process  of  dilating  a  stricture,  it  is  often 
advisable  to  allow  the  instrument  to  remain  in  the  bladder.  A 
silver  catheter  is  borne  with  rather  less  comfort  than  a  gum- 
elastic,  but  the  latter  soon  becomes  corroded  and  roughened 
by  the  action  of  the  urine  upon  it ;  hence  if  the  gum  catheter 
is  used,  it  should  be  removed  at  least  once  in  every  twenty- 
four  hours,  and  a  new  one  substituted  for  it. 

A  very  simple  mode  of  securing  the  catheter  in  the  blad- 
der is  the  following :  pass  a  ring  made  of  ivory  or  of  metal, 
covered  with  linen,  or  of  a  cylinder  of  linen  stuffed  with 
cotton,  over  the  penis,  and  secure  it  against  the  pubis  by 
means  of  four  tapes  passing  around  the  pelvis  and  between 


324         INTRODUCTION    OF    THE    CATHETER. 

the  thighs,  on  each  side ;  attach  the  catheter  to  this  ring  by 
tapes  connected  with  the  rings  of  the 
FlG- 165-  instrument,  or  tied  around  its  extremity, 

if  it  be  a  gum-elastic  tube. 

M.  Velpeau  advises  that  a  piece  of 
linen  be  passed  around  the  penis,  just 
behind  the  corona  glandis,  and  that  four 
tapes,  secured  to  the  rings  of  the  instru- 
ment, or  tied  around  the  extremity,  be 
twined  about  it.  (Fig.  165.)  The  first 
plan  will  be  less  likely  to  cause  injury 
to  the  penis,  in  case  of  erection  of  the 
organ. 

Catheterism  of  the  female  urethra  is 
attended  with  fewer  difficulties  than  that 
of  the  male,  owing  chiefly  to  the  differ- 
ence in  the  conformation  of  the  two  canals. 

The  instrument  employed  in  the  operation  is  made  of  silver, 
generally  ;  its  form  and  dimensions  may  be  very  well  seen  by 
a  reference  to  fig.  3,  A  and  B,  and  to  the  text  explanatory 
of  it.  But  a  gum-elastic  catheter,  even  without  a  stilet,  may 
easily  be  introduced.  The  only  difficulty  in  the  performance 
of  the  operation,  in  most  instances,  consists  in  inserting  the 
point  of  the  catheter  into  the  orifice  of  the  urethra,  without 
exposing  the  parts  ;  but  a  very  little  practice  upon  the  subject 
will  enable  the  surgeon  to  acquire  sufficient  skill  to  operate 
satisfactorily  on  the  living  female. 

The  simplest  rule  which  can  be  given  for  ascertaining  the 
position  of  the  orifice  of  the  urethra  in  the  female  is  this : 
(the  patient  being  on  her  back,)  introduce  the  tip  of  the  fore- 
finger of  the  right  hand  within  the  labia  and  the  orifice  of  the 
vagina,  and  press  its  palmar  surface  against  the  summit  of  the 
arch  of  the  pubis,  at  the  same  time  pushing  the  point  of  the 
finger  a  little  forwards ;  it  will  now  readily  and  immediately 
feel  itself  entering  the  mouth  of  the  canal,  which  is  forced  a 
little  open  to  admit  its  tip. 

The  catheter  may  be  thus  introduced  :  place  the  point  of 
the  forefinger  of  the  right  hand  at  the  orifice  of  the  urethra, 
as  just  directed,  and  with  the  left  hand  enter  the  catheter, 
using  the  finger  of  the  right  hand  as  a  guide ;  or  only  one 
hand  need  be  employed,  thus  :  lay  the  catheter  upon  the  palm 


INTRODUCTION    OF    THE    CATHETER.          325 

of  the  right  hand,  the  point  of  the  instrument  resting  on  the 
top  of  the  forefinger,  the  other  extremity  on  the  ball  of  the 
thumb,  and  supported  in  this  position  by  the  thumb  and 
middle-finger,  both  somewhat  flexed  ;  now  place  the  tip  of  the 
forefinger  at  the  orifice  of  the  urethra,  in  the  manner  already 
directed,  and  with  the  thumb  and  middle-finger  cause  the 
catheter  to  glide  along  upon  the  fore-finger  and  enter  the 
canal. 

When  the  uterus  is  higher  up  in  the  pelvis  than  usual,  from 
any  cause,  the  orifice  of  the  urethra  is  usually  drawn  behind 
the  arch  of  the  pubis ;  in  such  cases,  the  point  of  the  finger 
must  be  introduced  a  little  farther  than  is  otherwise  neces- 
sary, in  ascertaining  the  position  of  the  meatus,  and  rather 
behind  the  pubis ;  but  the  operation  is  scarcely  rendered  more 
difficult  on  this  account. 

It  sometimes  happens  that  the  urethra  is  much  compressed 
against  the  pubis  by  a  tumour  in  the  pelvis,  as  a  child's  head 
during  labour ;  in  such  circumstances,  if  it  is  necessary  to 
remove  the  urine  from  the  bladder,  a  gum-elastic  catheter  of 
small  size  should  be  used,  or,  which  is  perhaps  better,  a  flat- 
tened silver  catheter ;  such  an  instrument  can  be  had  at  the 
shops  of  surgical  instrument  makers. 

Should  it  be  deemed  advisable  to  allow  the  catheter  to  re- 
main for  any  length  of  time  in  the  bladder,  it  may  be  easily 
secured  by  applying  a  double-T  bandage  around  the  pelvis, 
and  attaching  the  rings  of  the  instrument  to  the  strips  which 
pass  between  the  thighs  and  over  the  perinseum. 

5.  CATHETERISM  OF  THE  LARGE  INTESTINE  is  sometimes 
resorted  to,  for  the  purpose  of  removing  the  gases  which  accu- 
mulate so  largely  in  some  diseases.  Thus,  in  peritonitis,  the 
bowels  often  become  so  much  distended  with  flatus,  as  to 
aggravate  the  patient's  suffering  in  a  high  degree.  In  such 
cases,  relief  is  occasionally  obtained  from  the  introduction  of 
the  common  stomach-tube.  The  mode  of  performing  the 
operation  is  simple  in  the  extreme ;  and  yet,  from  the  tortuous 
course  of  the  intestinal  canal,  it  is  often  exceedingly  difficult 
to  pass  the  tube  to  any  considerable  distance  above  the  rec- 
tum. The  most  successful  plan  is  to  select  a  large-sized 
stomach-tube,  having  within  it  a  stilet  of  whalebone  sufficiently 
thick  to  impart  to  the  tube  a  certain  degree  of  firmness,  yet 
so  flexible  as  to  accommodate  itself  to  the  winding  course  of 
28 


326     INTRODUCTION  OF  THE  CATHETER. 

the  canal ;  the  tube  should  be  oiled,  and  introduced  with  a 
rotatory  motion  and  slowly :  the  point  of  the  catheter  may 
often  be  felt  passing  along  the  sigmoid  flexure  of  the  colon, 
by  the  hand  placed  on  the  parietes  of  the  abdomen.  If  the 
operator  fail  in  his  first  attempt,  he  should  change  the  posi- 
tion of  the  patient,  and  make  another  effort.  It  is  sometimes 
useful,  when  the  farther  advance  of  the  tube  seems  to  be  pre- 
vented, to  throw  a  stream  of  tepid  water  through  it  from  a 
syringe  inserted  into  its  trumpet-shaped  orifice. 

6.  CATHETERISM  OF  THE  LARYNX  AND  TRACHEA  is  rarely 
practised  ;  but  in  some  cases  of  oedema  of  the  glottis  and 
similar  obstructions,  it  may  perhaps  be  advisable  to  pass  a 
tube  into  the  air-passages  from  the  mouth.  The  operation  is 
more  difficult  of  execution  than  catheterism  of  the  oesophagus ; 
sometimes,  indeed,  it  is  impossible,  as  when  the  rima  glottidis 
is  spasmodically  closed  :  the  patient  being  seated,  or  recum- 
bent, the  head  should  be  thrown  back,  the  mouth  widely 
opened,  and  the  base  of  the  tongue  depressed  by  means  of  a 
spoon ;  then  the  surgeon,  taking  a  silver  tube  curved  like  the 
ordinary  catheter  for  the  urethra,  but  rather  larger  and  open 
at  both  ends,  or  a  stomach-tube  curved  by  means  of  a  stilet, 
passes  it  through  the  mouth  directly  into  the  larynx,  the  pa- 
tient being  directed  to  prolong  his  inspiratory  act :  a  momen- 
tary cough  may  be  excited  by  the  entrance  of  the  tube  into 
the  larynx,  but  this  may  soon  subside,  so  that  the  instrument 
may  be  permitted  to  remain,  having  been  secured  by  attach- 
ing its  external  end  to  some  conveniently-placed  bandage,  as 
around  the  neck,  for  example. 


CHAPTER  VII. 

ON    THE    ADMINISTRATION    OF    INJECTIONS. 

THE  term  injections,  or  enemata,  is  applied  to  liquids  in- 
troduced into  the  canals  or  cavities  of  the  body  by  means  of 
syringes  contrived  for  the  purpose. 

The  matter  of  the  injection  consists  of  water,  holding  in 
solution,  or  suspension,  certain  medicinal  substances,  intended 
to  produce  some  special  effect, — or  of  water  alone. 

The  syringes  used  in  the  administration  of  enemata  vary  in 
form  and  size,  according  to  the  amount  of  fluid  to  be  injected, 
and  the  canal  into  which  it  is  to  be  introduced.  The  rectum, 
the  vagina,  the  urethra,  and  the  lachrymal  duct  are  the  pas- 
sages which  are  most  frequently  acted  upon  in  this  manner. 

1.  Injections  by  the  rectum. 

The  syringes  for  the  rectum  are  made  of  different  sizes,  to 
contain  from  two  fluid  ounces  to  a  pint,  or  more.  In  select- 
ing them,  those  instruments  should  be  chosen  of  which  the 
beaks  are  large  and  well-rounded  at  the  extremity,  so  that 
there  shall  be  less  probability  of  inflicting  any  injury  upon 
the  mucous  membrane  of  the  rectum  during  their  intro- 
duction. 

Before  using  the  syringe,  the  beak  should  be  warmed  and 
anointed  with  oil,  or  lard ;  and  when  it  is  being  introduced 
into  the  rectum,  great  gentleness  and  caution  should  be 
observed,  otherwise,  as  has  happened  at  times,  the  intestine 
may  be  torn,  or  even  perforated,  particularly  when  its  coats 
are  not  in  a  perfectly  healthy  condition.  Its  entrance  into 
the  anus  may  be  facilitated  by  first  passing  in  the  forefinger 
of  the  left  hand,  well  oiled,  and  then  sliding  in  the  beak  upon 
it.  While  the  piston  is  being  forced  down  with  the  right 
hand,  the  head  of  the  syringe  should  be  firmly  held  by  the 
fingers  of  the  left,  so  that  the  instrument  shall  not  be  pushed 
further  into  the  bowel.  The  fluid  should  be  forced  from  the 
tube  gradually  ;  and  after  all  has  been  ejected,  the  beak  of 

(327) 


328  ADMINISTHATION    OF    INJECTIONS. 

the  instrument  should  be  retained  a  few  moments  in  the 
rectum,  lest,  during  its  removal,  the  injection  pass  out  with  it. 

The  above  remarks  are  of  general  applicability :  there  are 
some  modifications  of  the  process,  however,  which  should  be 
borne  in  mind.  Thus,  it  is  frequently  advisable  that  a  large 
quantity  of  fluid  shall  be  thrown  into  the  bowel,  a  larger  quan- 
tity than  can  be  contained  in  the  syringe  usually  employed. 
In  such  cases,  the  instrument  must  be  carefully  and  slowly 
withdrawn  from  the  anus,  refilled,  and  again  introduced  and 
emptied,  until  the  requisite  amount  shall  have  been  injected ; 
or,  the  self-injecting  syringe  may  be  more  conveniently  used 
— an  instrument  made  like  the  common  forcing  pump,  having 
connected  with  it  one  tube,  through  which  the  fluid  enters  the 
syringe  from  the  vessel  which  contains  it,  and  a  second,  which 
is  inserted  into  the  rectum,  and  through  which  the  injection 
finds  its  way  into  the  bowel.  With  this  very  convenient  ap- 
paratus, any  quantity  of  fluid  may  be  thrown  into  the  large 
intestine,  until  it  is  filled,  either  by  the  patient's  self  or  by  an 
attendant.  Again,  it  sometimes  happens  that  an  obstruction 
of  the  lower  part  of  the  bowel  prevents  the  introduction  of  the 
matter  of  the  injection  beyond  a  certain  point,  if  the  ordinary 
method  be  adopted.  In  such  cases,  it  is  customary  to  pass  a 
stomach  tube,  in  the  manner  recommended  in  the  last  chap- 
ter, as  far  into  the  canal  as  may  be  practicable,  and  to  inject 
the  fluid  through  it.  This  method  will  be  found  effectual, 
oftentimes,  in  overcoming  the  constipation  which  attends  some 
cases  of  colic. 

The  composition  of  the  enema  must  be  adapted  to  answer 
the  particular  indication  for  which  it  is  given.  When  it  is 
employed  merely  to  distend  the  bowel  by  its  quantity,  simple 
warm  water,  or  warm  mucilage,  may  be  used.  The  ordinary 
purgative  injection  consists  of  a  -tablespoonful  of  common  salt 
and  the  same  bulk  of  molasses,  dissolved  in  a  pint  of  warm 
water,  to  which  a  small  piece  of  soap  may  be  added  with  ad- 
vantage. The  anodyne  enema  consists  merely  of  half  an  ounce 
or  an  ounce  of  mucilage,  holding  in  suspension  or  solution  the 
anodyne  element, — as,  for  example,  thirty-five  or  forty  drops 
of  laudanum.  This  small  quantity  of  fluid  is  preferred,  as 
being  less  likely  to  induce  contraction  of  the  expulsive  mus- 
cles by  its  mere  presence,  than  if  a  larger  amount  were  intro- 
duced; and  this  fact  should  be  recollected  in  giving  anyinjec- 


ADMINISTRATION    OF    INJECTIONS.  329 

tion  which  is  intended  to  be  retained  in  the  rectum,  to  pro- 
duce some  general  impression  upon  the  economy. 

"  Suppositories"  are  sometimes  used  as  substitutes  for  ene- 
mata :  they  may  be  so  formed  as  either  to  induce  an  evacua- 
tion of  the  lower  bowel,  from  the  irritation  of  their  presence 
in  the  rectum, — or,  in  consequence  of  the  absorption  of  the 
medicated  materials  of  which  they  are  composed,  they  may  be 
retained  for  a  considerable  length  of  time  in  the  gut,  and  pro- 
duce the  peculiar  effect  of  the  medicine  upon  the  system. 

The  suppository  intended  to  produce  catharsis  is  ordinarily 
made  of  a  piece  of  castile  soap  cut  to  correspond  with  the 
form  and  size  of  the  rectum ;  it  should  be  oiled,  and  then  in- 
serted gently  within  the  sphincter  muscle. 

Any  medicine  may  be  administered  in  the  form  of  a  sup- 
pository, by  combining  it,  in  the  state  of  powder,  with  liquo- 
rice, cocoa-butter,  or  some  other  soft  adhesive  substance  ;  then, 
having  reduced  the  mass  to  the  proper  dimensions  and  figure, 
let  it  be  oiled  and  introduced  nuo  the  lower  extremity  of  the 
rectum.  As  a  general  rule,  the  quantity  of  the  medicine  used 
in  the  suppository  may  be  three  or  four  times  greater  than 
the  proportion  of  the  same  medicine,  when  given  by  the 
mouth. 

It  should  be  borne  in  mind  that  a  very  frequent  resort  to 
the  employment  of  suppositories,  or  to  the  administration  of 
injections,  produces  irritation  of  the  mucous  membrane  lining 
the  lower  part  of  the  rectum,  and  is  apparently  an  exciting 
cause  of  the  development  of  haemorrhoids  and  other  organic 
alterations  of  this  portion  of  the  intestinal  canal. 

2.  Injections  by  the  vagina. 

The  vaginal  syringe  is  usually  about  four  inches  long  and 
an  inch  in  diameter,  terminating  in  a  rounded  head  which  is 
pierced  with  a  number  of  holes,  like  a  sieve. 

No  especial  directions  are  required  to  enable  one  to  intro- 
duce this  instrument,  farther  than  that  it  should  be  oiled  be- 
fore so  doing. 

The  cavity  of  the  uterus  itself  may  be  washed,  by  passing 
a  gum-elastic  catheter  through  the  os  uteri,  and  injecting  the 
interior  of  the  organ  with  tepid  water  or  mucilage,  by  means 
of  an  ordinary  syringe,  of  which  the  beak  is  inserted  into  the 
open  extremity  of  the  catheter. 

3.  Injections  by  the  urethra. 

28* 


330  ADMINISTRATION    OF    INJECTIONS. 

A  small  glass  syringe  capable  of  containing  about  half  an 
ounce,  and  having  a  beak  well  rounded  at  the  tip,  is  the  best 
instrument  for  injecting  the  urethra.  The  piston  should  ter- 
minate, at  its  free  extremity,  in  a  ring  large  enough  to  receive 
the  thumb,  so  that  the  fluid  may  be  forced  from  the  syringe 
and  the  syringe  itself  held  by  the  right  hand,  while  the  left 
supports  the  penis.  The  beak  of  the  instrument  should  be 
oiled  and  inserted  very  carefully  into  the  orifice  of  the  ure- 
thra, lest  the  lining  membrane  be  injured. 

It  is  generally  recommended  that  pressure  be  made  upon 
the  perinseum  opposite  the  neck  of  the  bladder,  in  order  to 
prevent  the  fluid  of  the  injection  from  entering  the  cavity  of 
this  organ  ;  but  this  precaution  is  scarcely  necessary,  if  the 
piston  of  the  syringe  is  forced  down  with  a  proper  degree  only 
of  rapidity,  and  if  only  sufficient  fluid  be  expelled  to  fill  the 
canal, — the  sphincter  muscle  preventing  the  fluid  from  reach- 
ing the  bladder  itself. 

The  interior  of  the  bladder  may  be  acted  upon  by  fluid  in- 
jected through  the  urethra,  a  catheter  having  been  first  intro- 
duced, and  the  beak  of  an  ordinary  syringe,  or  a  gum-elastic 
.bag,  then  inserted  into  the  mouth  of  the  tube.  But  it  is  much 
more  convenient  to  use  a  catheter  having  two  passages,  as  in 
fig.  166.  In  the  drawing  the  division  of  the  tube  is  indicated 
by  the  dotted  line  and  the  star ;  at  a  the  nozzle  of  the  syringe 
(a)  is  received ;  the  fluid  from  the  latter  passes  along  to  the 
bladder  through  the  eye  marked  by  one  of  the  arrows,  and  is 
returned  from  the  bladder  through  that  marked  by  the  other, 
to  escape  from  the  catheter  by  d.  The  stilet  c  is  for  the  pur- 
pose of  removing  any  obstruction  which  may  occur  in  the  ca- 
theter;  it  is  made  of  steel,  so  thin  and  flexible  as  to  be  capable 
of  being  readily  pushed  into  the  chambers  of  the  instrument, 
as  indicated  by  the  dotted  curved  line.  (See  Mr.  Fergusson's 
book,  p.  588.) 

Care  should  be  taken,  that  the  fluid  thus  introduced  into 
the  bladder  has  been  freed  from  all  solid  matter  which,  if  re- 
tained, would  serve  as  the  nucleus  for  calculous  formations ; 
it  should,  moreover,  be  tepid  in  temperature,  and  of  a  slightly 
mucilaginous  character. 

In  injecting  the  urethra  of  the  female,  a  catheter  should 
first  be  inserted  within  the  orifice  of  the  canal,  the  beak  of  the 


ADMINISTRATION    OF    INJECTIONS.  331 

FIG.  166. 


syringe  adapted  to  it,  and  then  the  fluid  forced  through  the 
tube  into  the  urethra. 

4.  Injection  by  the  lachrymal  duct. 

The  instrument  by  means  of  which  this  is  accomplished,  is 
known  by  the  name  of  "  Anel's  syringe ;"  it  is  a  small  syringe 
having  a  number  of  very  fine  tubes  appertaining  to  it,  one  of 
which,  when  the  duct  is  to  be  injected,  is  attached  to  the  beak 
of  the  syringe  and  then  inserted  into  the  inferior  puncture 
lachrymal.  The  method  of  using  the  instrument  is  thus  de- 
scribed by  Malgaigne  :  "  Seat  the  patient  opposite  the  light. 
If  you  operate  on  the  left  eye,  stand  before  him,  and  with 
the  thumb  or  fingers  of  your  left  hand  draw  the  lower  lid  out- 
wards and  a  little  downwards,  so  as  to  direct  the  lachrymal 
puncture  forwards  and  outwards.  Then,  having  filled  the 
syringe  and  applied  one  of  the  small  tubes  to  the  beak,  hold 
the  instrument  as  a  pen  in  your  right  hand,  which  you  rest 
on  the  cheek,  and  carefully  insert  the  end  of  the  tube  in  the 
puncture ;  first,  obliquely  downwards  and  inwards,  then,  after 
having  entered  one  line,  directly  inwards.  At  the  distance 
of  three  and  a  half  lines  you  may  stop,  but  it  is  advisable  to 
penetrate  as  far  as  four  and  a  half  lines,  in  order  to  reach  the 


332     ADMINISTRATION  OF  INJECTIONS. 

sac;  then  inject  slowly,  at  first."  On  the  right  eye  the  ope- 
ration may  be  performed  also  with  the  right  hand,  by  stand- 
ing behind  the  patient,  and  resting  the  hand  upon  the  exter- 
nal orbital  process  of  the  frontal  bone.  If  the  duct  is  pervi- 
ous, the  fluid  thus  injected  will  pass  through  it  and  appear 
externally  by  the  nostril ;  and  if  it  be  not  pervious  at  first, 
the  obstruction  may  oftentimes  be  removed  by  repeated  use 
of  the  syringe.  The  first  injection  should  consist  of  tepid 
water  or  mucilage ;  subsequently,  the  fluid  may  be  rendered 
somewhat  astringent,  or  be  otherwise  medicated.  If  the  in- 
jection cannot  be  passed  through  the  duct,  a  fine  silver  probe, 
of  which  the  point  is  round  and  smooth,  may  be  introduced 
as  directed  for  the  syringe. 


CHAPTER  VIII. 

ON   THE   REMOVAL   OF   FOREIGN   BODIES   FROM   THE    NATURAL 
CANALS   AND   PASSAGES. 

1.  THE  GLOBE  OF  THE  EYE,  from  its  exposed  position,  is  very 
liable  to  have  foreign  bodies,  as  particles  of  dust,  cinders,  and 
minute  insects,  come  in  contact  with  it;  not  unfrequently, 
also,  sharp  splinters  of  iron  or  steel  are  driven  forcibly  against 
it  and  imbed  themselves.  The  pain  in  such  instances  is  con- 
siderable, sometimes  excruciating ;  more  or  less  profuse 
lachrymation  takes  place,  and  the  patient  is  unable  for  a  time 
to  make  use  of  the  eye  without  discomfort. 

Frequently,  the  profuse  secretion  and  escape  of  tears  are 
sufficient  to  wash  away  the  offending  substance,  aided  by  the 
friction  which  the  patient  almost  unwillingly  exercises.  When 
not  thus  removed,  the  lids  should  be  well  opened  and  the  globe 
carefully  examined,  while  the  patient  rolls  the  eye-ball  in 
various  directions ;  if  the  object  be  thus  brought  into  view,  it 
may  be  removed  by  the  point  of  a  camel's-hair  pencil,  by  the 
corner  of  a  pocket  handkerchief,  the  end  of  a  tooth-pick  or 
probe ;  or  it  may  be  necessary  to  throw  a  fine  stream  of  tepid 
water  gently  between  the  lids ;  or,  finally,  if  a  particle  of 
metal  or  such  body  be  adherent  to  the  structure,  it  must  be 
removed  by  a  pair  of  delicate  forceps,  or  by  the  point  of  a 
cataract  needle ;  in  such  cases  a  magnet  would  hardly  accom- 
plish the  removal. 

Very  generally  the  offending  object  will  not  be  detected  by 
the  examination  to  which  we  have  alluded ;  it  will  then  be 
necessary  to  scrutinize  the  inner  surface  of  the  eye-lids. 
The  lining  membrane  of  the  lower  lid  may  be  readily  seen  by 
depressing  the  lid,  at  the  same  time  that  the  patient  rolls  the 
eye  upwards ;  to  expose  the  conjunctiva  of  the  upper  lid,  the 
surgeon  should  seize  the  lashes,  and  by  these  draw  the  lid  a 
little  off  from  the  globe,  place  a  probe,  a  tooth-pick,  or  some 
similar  instrument,  across  the  lid  just  above  the  superior 
border  of  the  cartilage  and  parallel  thereto,  and,  while  the 
patient  looks  downwards  as  much  as  possible,  throw  the  lid 

(333) 


334  REMOVAL    OF    FOREIGN    BODIES 

over  the  probe,  thus  turning  it  " inside  out;"  all  these  steps 
are  done  at  once.  If  the  object  be  seen,  it  may  be  removed 
by  any  of  the  means  above  indicated. 

It  must  be  recollected  that  the  sense  of  itching,  pain,  &c., 
occasioned  by  the  pressure  of  the  irritating  substance,  usually 
remains  some  time  after  the  cause  has  been  removed.  This 
disturbance,  however,  will  commonly  be  relieved  by  the  ap- 
plication upon  the  closed  lids  of  tepid  or  cold  water,  as  is 
most  agreeable  to  the  patient. 

2.  REMOVAL  OF  FOREIGN  SUBSTANCES  FROM  THE  NOSTRIL. 
—  Children  are  not  inapt  to  thrust  beans,  coffee  grains,  but- 
tons, and  such  small  bodies,  into  their  own  or  others'  nostrils, 
in  fun  or  malice ;  or  they  may  be  drawn  up  into  the  nose  by 
smelling  them  strongly.  Careless  or  ignorant  manipulation, 
instead  of  dislodging  them,  only  forces  them  farther  towards 
the  summit  of  the  nasal  chamber.  The  lining  membrane  of 
the  nose  becomes  swollen,  in  consequence  of  the  pressure  of 
the  irritant  and  of  the  efforts  made  to  remove  it,  blood  flows 
more  or  less  freely  from  the  ruptured  vessels,  and  the  cavities 
become  additionally  occluded  by  clots  of  blood.  When  the 
surgeon  is  sent  for  he  finds  the  inside,  and  perhaps  also  the 
exterior,  of  the  organ  swollen,  and  is  unable  to  see  the  offending 
substance.  In  such  a  case,  it  is  best  to  syringe  the  nose  with 
tepid  water,  to  dislodge  coagula  of  blood,  and  inspissated  mucus 
which  obscure  the  cavity  ;  perhaps  the  same  means  will  likewise 
loosen  and  wash  down  the  foreign  body ;  if  not,  let  the  sur- 
geon pass  a  flattened  probe,  slightly  curved,  into  the  nose 
beyond  the  object,  and  endeavour  to  drag  it  downwards ;  the 
spoon-shaped  extremity  of  the  silver  director  will  answer  this 
purpose  very  well;  or  the  substance  may  sometimes  be  caught 
in  the  noose  of  a  wire-armed  canula.  Either  of  these  instru- 
ments will  be  more  likely  to  succeed  in  engaging  the  object 
sought  than  the  forceps,  for  the  latter  cannot  usually  be 
worked  with  advantage,  and  even  if  the  foreign  substance  be 
grasped,  it  will  slip  from  the  blades  repeatedly. 

If  it  be  not  thrust  high  up  in  the  nose,  and  only  loosely 
fixed,  it  may  be  dislodged  by  exciting  violent  sneezing,  the 
other  nostril  being  closed  the  while. 

Occasionally,  children  are  so  much  frightened  by  the  acci- 
dent and  the  efforts  made  to  relieve  them,  as  to  be  entirely 
unmanageable,  and  thereby  expose  themselves  to  injury  from 


FROM  THE  NATURAL  CANALS. 


335 


FIG.  167 


attempts  at  extraction  of  the  foreign  body.  It  is  better, 
under  these  circumstances,  to  quiet  the  patient  by  inhalations 
of  ether,  and  then  resume  the  operation  under  more  favour- 
able auspices,  or  to  wait  until  the  dread  shall  have  passed  off. 
There  is  usually,  however,  no  such  difficulty. 

Soothing  applications  should  be  made  after  the  operation, 
if  the  local  symptoms  seem  to  require  any  interference. 

3.  EXTRACTION  OF  FOREIGN  BODIES  FROM  THE  EXTERNAL 
MEATUS  OF  THE  EAR. — The  lining  membrane  of  the  external 
auditory  passage,  especially  near  the  mem- 
brana  tympani,  is  so  exquisitely  sensitive, 
that  great  pain  and  irritation,  sometimes 
convulsions,  are  produced  by  the  entrance 
of  foreign  substances.  Insects,  the  most 
common  of  which  is  the  "ear-wig,"  splin- 
ters, small  pebbles,  &c.,  &c.,  are  not  un- 
frequently  introduced,  or  insinuate  them- 
selves into  the  external  ear.  Attempts  to 
remove  them  should  be  made  with  great 
delicacy,  as  very  unpleasant  consequences 
have  often  followed  carelessness  and  rude- 
ness. 

The  passage  should  be  examined  by  the 
aid  of  the  speculum,  such  as  is  represented  in 
fig.  167,  a  conical  silver  tube  carefully  smoothed,  and  brightly 
polished  on  the  inner  surface,  or  the  little  gorget-like  instru- 
ment shown  in  fig.  168 ;  and  if  the  object  be  seen,  it  may, 

FIG.  168. 


perhaps,  be  removed  by  a  flattened  silver  probe,  slightly 
curved,  or  the  scoop-shaped  end  of  a  director,  or  the  little 
curvette,  or  the  delicate  forceps,  used  by  Mr.  Wilde.  (Fig. 
169.)  In  consequence  of  the  straightness  of  the  passage, 
however,  the  surgeon  may  not  be  able  to  manipulate  conve- 
niently with,  or  guide,  any  of  the  instruments  to  which  we 


336  REMOVAL    OF    FOREIGN    BODIES 

FIG.  169. 


have  alluded,  his  hand  being  in  the  way  of  his  vision ;  he  will 
then  find  the  forceps  illustrated  in  fig.  170,  more  manageable. 


FIG.  170. 


But  in  most  cases,  more  can  be  done,  perhaps,  by  means  of  a 
syringe  and  tepid  water,  than  by  any  other  instrument,  and 
with  less  danger  of  injuring  the  patient ;  this  is  particularly 
true  if  an  insect  have  found  its  way  into  the  meatus,  or  if 
wax  have  became  impacted  therein. 

It  is  necessary  to  guard  against  inflammation,  both  before 
and  after  the  removal  of  foreign  bodies  from  this  situation. 
(See  Wilde's  Aural  Surgery.) 

4.  Foreign  bodies  occasionally  become  lodged  in  the 
Pharynx  and  (Esophagus.  Small  objects,  such  as  pins,  but- 
tons, fish  bones,  are  apt  to  become  arrested  in  the  folds  and 
pouches  at  the  base  of  the  tongue  and  palate,  causing  con- 
siderable uneasiness  and  constant  coughing  and  hawking, 
rather  than  actual  strangling ;  while  bodies  of  larger  size  are 
caught  at  the  narrowest  part  of  the  pharynx,  and  by  their 
pressure  upon  the  larynx,  or  the  spasmodic  irritation  which 
they  produce  in  it,  endanger  suffocation. 

The  exact  point  of  lodgement  should  first  be  ascertained, 
by  careful  exploration  with  the  fore-finger  of  the  right  hand, 
as  well  as  by  the  eye,  of  the  surgeon  —  the  patient's  mouth 


FKOM  THE  NATURAL  CANALS. 


337 


being  widely  opened.  The  situation  having  been  determined, 
the  surgeon  may  best  remove  the  offending  object  by  his  finger- 
nail, or  by  a  pair  of  dressing-forceps,  if  it  be  not  too  low 
down. 

If  the  substance  in  question  be  impacted  in  the  oesophagus, 
its  situation  must  be  ascertained  by  sounding  with  the  pro- 
bang,  (fig.  171,)  a  flexible  rod  of  smooth  whalebone,  tipped 

FIG.  171. 


with  a  sponge,  or  rounded  block  of  ivory ;  if  it  be  low  down, 
near  the  stomach,  probably  the  best  course  to  pursue  is  to 
push  it  still  onward  into  this  cavity,  by  means  of  the  pro- 
bang  ;  if  it  be  nearer  to  the  pharynx  and  accessible  to  instru- 
ments, the  effort  should  be  made  to  seize  it  with  the  gullet- 
forceps,  as  represented  in  fig.  172 ;  or,  instead  of  the  forceps, 

FIG.  172. 


29 


338  REMOVAL    OP    FOREIGN    BODIES 

a  hook  attached  to  a  whalebone,  as  is  exhibited  in  fig.  173, 


FIG.  173. 


may  be  passed  between  the  body  and  the  wall  of  the  oesopha- 
gus, and  then,  when  it  is  beyond  the  former,  drawn  up  again ; 
the  instrument  being  provided  with  a  hinge,  which 
FIG.  174.    permits  its  blades  to  close  as  it  is  pressed  between 
the  gullet  and  the  foreign  body,  while  they  open 
again  when  the  pressure  is  removed,  and  thus  en- 
tangle the  latter. 

But  a  much  more  simple  and  effectual  hook  is 
that  contrived  by  Dr.  Bond,  of  this  city  (fig.  174) ; 
it  is  so  simple  that  many  may  be  inclined  to  think 
little  of  it.  It  is  longer  than  the  common  gullet- 
hook,  and  sets  out  rather  more  from  the  stem  at  its 
extremity,  while  at  its  commencement  it  forms  quite 
an  acute  angle  with  the  shaft,  and  is  thus  capable 
of  engaging  objects  so  small  as  a  pin  or  a  needle.  It 
is  made  upon  a  piece  of  copper  wire,  silvered,  or 
upon  a  piece  of  silver  wire,  long  enough  to  reach 
even  to  the  stomach,  and  sufficiently  flexible  to  be  moulded  to 
any  shape.  It  will  be  found  to  be  a  most  efficient  instru- 
ment ;  indeed,  one  can  accomplish  more  with  it  than  with  any 
other  means. 

It  is  very  well  to  have  two  pair  of  gullet-forceps,  opening 
in  opposite  directions,  as  those  figured  by  Professor  Miller, 
(fig.  175) ;  in  these,  it  will  be  observed,  the  inner  face  of  each 
blade  is  flat,  and  toothed  near  the  extremity.  Dr.  Bond  has 
also  contrived  a  gullet-forceps,  (see  fig.  176),  the  inner  face 
of  whose  blades  are  levelled  off  towards  each  other,  and 
toothed ;  and  they  are  so  set  that  they  do  not  come  together 
closely ;  consequently,  there  is  but  little  probability  of  catch- 
ing the  lining  membrane  of  the  oesophagus  between  them. 


FROM  THE  NATURAL  CANALS.       339 
FIG.  175.  FIG.  176. 


These  forceps  are  in  general  use  in  this  city,  and  are  prefer- 
able, we  think,  to  all  others.  (See  an  interesting  paper  by 
Dr.  Bond,  in  the  North  American  Med.  and  Surg.  Journal, 
vol.  vi.,  in  which  he  describes  both  the  forceps  and  the  hook.) 
Sometimes,  though  happily  very  rarely,  it  is  impossible 
either  to  draw  the  body  upwards,  or  to  force  it  into  the  sto- 


340  KEMOVAL    OF    FOREIGN    BODIES 

mach ;  then,  if  the  symptoms  be  urgent,  it  remains  only  to 
make  an  incision  upon  it  at  the  side  of  the  neck,  and  remove 
it  from  without. 

If  the  foreign  substance  be  withdrawn  from  the  gullet,  it 
is  advisable  always  that  the  patient  should  make  use  of  some 
mucilaginous  article,  as  slippery-elm  bark,  or  gum  arabic,  to 
lubricate  the  lining  membrane  and  to  protect  it,  while  so  re- 
cently irritated,  from'  farther  annoyance  during  the  passage 
of  alimentary  substances.  And  if  the  offending  object  have 
been  pressed  down  into  the  stomach,  especially  if  it  be  irrita- 
ting, unless  it  be  chemically  so,  rather  than  give  purgative 
medicines  to  promote  its  evacuation  per  anum,  demulcients 
and  mucilages  should  be  taken  freely  by  the  patient,  in  the 
hope  that  it  may  become  more  or  less  ensheathed,  and  thus 
be  rendered  harmless :  if  it  be  likely  to  do  mischief  by  chemi- 
cal action,  the  proper  antidote  should  be  promptly  and  suf- 
ficiently administered. 

5.  EXTRACTION  OF  FOREIGN  BODIES  FROM  THE  LARYNX  AND 
TRACHEA. — During  the  act  of  inspiration,  the  glottis  is  opened 
widely  for  the  ingress  of  air,  while  but  a  narrow  chink  re- 
mains during  expiration.  Hence,  during  a  fit  of  crying, 
laughing,  coughing,  yawning,  or  the  like,  the  unusual  inward 
rush  of  air  often  suffices  to  suck  in,  so  to  speak,  bodies  of 
considerable  size.  Among  the  articles  which  have  been  thus 
drawn  into  the  trachea,  are  pieces  of  money,  (a  half  sovereign, 
for  example,)  cherry  and  plum  stones,  small  pebbles,  grains 
of  coffee  and  corn,  teeth,  (in  one  instance,  a  large  molar  with 
its  fangs,)  pieces  of  grass,  fragments  of  bone.  The  object 
once  in,  escape  is  difficult,  from  the  diminished  size  of  the 
orifice,  but  especially  from  the  spasmodic  closure  of  the  glottis, 
which  the  presence  of  an  irritant  almost  necessarily  induces. 

The  symptoms  produced  by  this  accident  vary  according 
to  the  position  occupied  by  the  intruder.  If  it  be  fixed  in 
the  rima  glottidis,  asphyxia  is  rapidly  produced,  and  speedy 
loss  of  consciousness  and  death,  unless  relief  is  procured  by 
surgical  interference.  If  it  be  moveable  in  the  larynx  and 
trachea,  and  if  it  change  its  position  from  time  to  time,  these 
alterations  of  site  may  occasion  violent  spasmodic  cough,  con- 
tinuing until  complete  exhaustion  is  produced,  when  a  tem- 
porary cessation  occurs,  to  be  followed,  upon  revival,  by  the 
same  phenomena.  In  other  cases,  the  cough  is  only  occa- 


FROM  THE  NATURAL  CANALS. 


341 


sional  and  much  less  violent,  resembling  more  the  paroxysms 
of  hooping-cough ;  again,  it  is  more  like  that  which  attends 
an  ordinary  catarrh,  or  a  pneumonia,  so  as  to  be  mistaken  for 
one  of  these ;  the  nature  of  the  expectoration  is  also  similar 
to  that  of  these  affections.  Auscultation  will  aid  the  recog- 
nition both  of  the  cause  of  these  aberrations,  if  the  history 
have  been  unknown,  and  of  the  portion  of  the  body,  es- 
pecially if  it  be  impacted  anywhere,  because  such  a  condition 
almost  always  occasions  local  pneumonia,  or  collapse  of  that 
portion  of  the  pulmonary  structure  which  is  connected  with 
the  bronchial  tube  thus  occluded.  Frequently,  too,  the  exist- 
ence of  the  foreign  body  in  the  trachea  and  larynx,  may  be 
recognised  by  feeling  it  with  the  fingers  placed  on  the  outside 
of  the  passage,  and  its  motions  up  and  down  in  the  tube  may 
thus  be  followed.  Besides  the  local  symptoms  enumerated, 
the  general  condition  of  the  patient  suffers,  he  becomes  ema- 
ciated, feverish,  &c. ;  in  fact,  many  persons  who  have  acci- 
dentally had  a  foreign  body  lodged  in  the  trachea,  have  been 
supposed  to  labour  under  tuberculous  diseases  of  the  lungs. 

The  cause  of  all  these  troubles  may  remain  entangled  in 
the  ventricles  and  folds  of  the  larynx,  or  be  impacted  in  its 
general  cavity,  or  in  that  of  the  trachea ;  it  may  have  passed 
into  one  of  the  bronchia,  the  right  most  probably,  because  of 
the  size  and  direction  of  the  latter  ;  it  may  even  slip  farther 
down  into  one  of  the  smaller  subdivisions  of  the  bronchial 
tubes ;  or  it  may,  as  we  before  hinted,  be  arrested  at  the  chink 
of  the  glottis,  either  at  its  first  descent,  or  subsequently 
during  expiration. 

Before  resorting  to  mechanical  interference,  the  surgeon 
should  satisfy  himself  by  careful  investigation  into  the  history, 
as  well  as  the  present  phenomena,  of  the  case,  that  a  foreign 
body  has  passed  into  the  respiratory  canal,  and  that  the  symp- 
toms are  not  due  to  inflammation,  nor  to  impaction  in  the 
oesophagus  or  pharynx. 

Clearly,  the  attempt  at  removal  of  the  object  in  question, 
by  forceps  passed  into  the  larynx  and  trachea,  is  out  of  the 
question.  The  surgeon  must  decide  between  performing  tra- 
cheotomy and  laryngotomy  ;  and  removing  the  body  through 
the  wound,  on  the  one  hand,  and  trusting  to  the  expulsive 
efforts  of  the  patient,  aided  by  the  surgeon.  The  first  of 
29* 


342  REMOVAL    OP    FOREIGN    BODIES 

these  proceedings  does  not  concern  us  in  this  treatise  ;  we 
refer  our  readers  to  works  on  practical  surgery. 

As  regards  the  second  course,  it  is  very  encouraging  to  find 
that  Nature  does  often  accomplish  the  extrication  of  the 
patient  from  circumstances  of  great  peril ;  but  the  surgeon 
should  he  prepared  to  step  in  at  any  moment  and  perform 
the  operation,  if  suffocation  be  imminent,  or  if  there  seem  to 
be  a  probability  that  the  longer  sojourn  of  the  foreign  body 
in  its  abnormal  situation  will  cause  the  death  of  the  patient 
by  the  irritation,  inflammation  and  exhaustion,  which  it 
occasions. 

If  violent  spasmodic  cough  be  induced  at  any  time,  with- 
out tending  to  cause  the  extrusion  of  the  foreign  body,  but 
serving  only  to  wear  out  the  patient's  strength,  it  may  be  well 
to  try  the  effect  of  anaesthetic  inhalation,  to  diminish  the  sen- 
sibility of  the  air-passages,  unless  the  substance  be  supposed 
to  be  impacted  at  the  glottis ;  and  even  then,  the  inhalation 
might  have  the  effect  of  extricating  it  from  its  present  position 
by  relaxing  the  muscular  spasm.  Again,  if  a  violent  fit  of 
coughing  be  induced,  the  patient  should  be  inverted,  and  at 
the  same  time  struck  smartly  between  his  shoulders ;  by  these 
simple  means  the  air-passages  have  been  relieved  of  their 
troublesome  occupant. 

In  the  well  known  case  of  Mr.  Brunei,  the  engineer  of  the 
Thames  tunnel,  an  apparatus  was  constructed,  with  a  hinge 
in  its  centre,  upon  which  he  was  extended ;  so  that  one  end 
being  elevated,  the  other  was  depressed,  and  thus  the  patient 
was  inverted  with  as  little  suffering  and  fatigue  to  himself  as 
possible.  Tracheotomy  was  performed  by  Sir  B.  Brodie,  but 
all  efforts  to  remove  the  foreign  body  (a  half  sovereign),  by 
forceps  introduced  through  the  wound,  were  unsuccessful; 
the  wound,  however,  was  kept  open,  and  on  the  16th  day  after 
the  operation,  the  patient  being  extended  upon  his  platform, 
by  dint  of  striking  his  back  sharply,  the  coin  quitted  the 
trachea  and  fell  into  the  mouth. 

In  conclusion,  we  may  say  with  Mr.  Fergusson,  that  such 
examples  as  this,  of  which  there  are  several  on  record, 
"  clearly  indicate  the  propriety  of  trying  the  effect  of  change 
of  attitude  in  such  cases ;  for  when  we  reflect  how  often  per- 
sons have  died  in  consequence  of  the  pressure  of  foreign 
bodies  in  the  air-passages,  and  how,  too,  occasionally  such 


FROM    THE    NATURAL    CANALS.  343 

bodies  have  been  spit  up  after  months  or  years  of  almost  con- 
tinued coughing  and  suffering,  it  is  not  unreasonable  to  sup- 
pose that  such  a  change  of  attitude,  and  some  such  additional 
measures  as  were  resorted  to  by  the  gentlemen  who  conducted 
the  treatment  of  the  instances  above  referred  to,  might  have 
saved  many  lives." 

For  farther  details  on  this  important  subject,  we  refer  to 
Dr.  Gross'  valuable  monograph  on  "  Foreign  Bodies  in  the 
Air-Passages,"  Philadelphia,  1854;  Dr.  Stokes's  book  on 
Diseases  of  the  Chest ;  to  an  interesting  paper  by  Dr.  Davis, 
in  the  New  York  "  American  Monthly,"  August,  1854;  to 
Brodie's  case,  London  Medical  Gazette,  July,  1843 ;  and  to 
Mr.  Porter's  treatise  on  the  Larynx  and  Trachea. 

6.  REMOVAL  OF  FOREIGN  BODIES  FROM  THE  URETHRA.  — 
The  urethra  of  both  sexes  is  liable  to  be  blocked  up,  more  or 
less  effectually,  by  the  lodgement  therein  of  fragments  of 
calculi,  portions  of  catheters  or  bougies  which  have  been 
broken  during  operations,  or  by  foreign  substances  introduced 
from  malicious  or  otherwise  improper  motives.  The  seat  of 
the  obstruction  varies — it  may  exist  at  any  point.  The  symp- 
toms are,  more  or  less  complete  retention  of  urine,  local  in- 
flammation and  pain.  The  precise  point  of  obstruction  can  be 
ascertained  sometimes  by  manipulation  of  the  exterior  of  the 
canal ;  more  certainly  by  the  introduction  of  a  catheter  or 
bougie. 

To  remove  the  foreign  body,  it  will  be  necessary  sometimes 
10  resort  to  many  expedients.  The  simplest  is  to  introduce 
the  largest  sized  bougie  of  catheter  down  to  the  substance, 
hoping  that  by  this  great  dilatation  of  the  canal  in  advance 
of  the  latter,  it  may  be  disengaged  and  forced  out  by  the 
pressure  of  the  urine  from  behind ;  or  the  ingenious  little  in- 
strument of  Leroy  d'Etiolles,  should  be  passed  behind  the 
impediment,  then  its  arm  thrown  down,  and  both  withdrawn ; 
or,  again,  a  long  slender  urethral  forceps,  such  as  is  shown  in 
fig.  177,  may  be  passed  up  to  the  obstacle,  and  efforts  made 
to  grasp  the  latter  with  it,  and  if  necessary  the  body  may  be 

FIG.  177. 


344 


REMOVAL    OF    FOREIGN    BODIES 


drilled  or  crushed  at  the  same  time.  If  the  impediment  be 
located  near  the  orifice  of  the  urethra,  it  may  perhaps  be 
seized  with  a  pair  of  delicate  dressing-forceps,  or  a  loop  of 
wire,  or  be  drawn  out  by  means  of  a  bent  probe ;  or  the 
canal  may  be  dilated  by  the  aid  of  Arnott's  fluid  dilator,  or 
Weiss'  metallic  dilator.  (Fig.  178.) 

FIG.  178. 


If  none  of  these  experiments  be  successful,  nothing  re- 
mains save  to  cut  down  upon  the  foreign  body  and  extract  it 
through  the  wound.  This  proceeding,  however,  will  rarely 
be  necessary  in  the  case  of  the  female  urethra,  foreign  bodies 
being  extricated  from  it  with  comparative  facility,  owing  to 
its  straightness,  shortness  and  capacity  for  dilatation. 

7.  REMOVAL  OF  FOREIGN  BODIES  FROM  THE  VAGINA,  can 
generally  be  accomplished  without  difficulty,  if  patience  and 
gentleness  be  used,  together  with  a  sufficiency  of  olive  oil. 
The  passage  is  susceptible  of  very  considerable  dilatation, 
and  consequently  it  can  rarely  be  necessary  to  divide  its  walls 
with  a  cutting  instrument ;  the  forceps  and  lever  employed  in 
obstetric  operations,  may  also  be  resorted  to  advantageously 
in  the  case  in  consideration. 

8.  REMOVAL  OF  FOREIGN  BODIES  FROM  THE  RECTUM. — 
Indigestible  substances  occasionally  pass  down  from  the  upper 
part  of  the  alimentary  canal,  and  become  arrested  in  the 


FROM    THE    NATURAL    CANALS.  345 

rectum ;  or  from  morbid  sensibility  of  the  mucous  membrane, 
and  a  resulting  spasmodic  stricture  of  the  orifice  of  the  gut, 
faeces  accumulate  in  large  masses,  so  as  not  only  to  exercise 
a  prejudicial  influence  upon  digestion,  but  likewise  to  encroach 
upon  the  other  organs  contained  in  the  pelvis ;  or,  finally, 
bodies,  various  in  kind  and  size,  may  be  introduced  into  the 
canal  from  without. 

To  ascertain  the  nature,  dimensions  and  situation  of  the 
abnormal  contents  of  the  rectum,  the  fore-finger,  well  oiled, 
should  be  passed  into  the  bowel,  or  if  this  be  not  sufficiently 
long,  a  metallic  or  gum-elastic  bougie  may  be  introduced. 

If  the  intestine  be  occluded  by  a  mass  of  hardened  faecal 
matter,  it  may  be  removed  by  throwing  up  an  abundance  of 
tepid  water  from  a  syringe  or  gum-elastic  bag,  which  will 
soften  the  accumulation  and  wash  it  down  little  by  little ;  or 
a  scoop,  a  tea-spoon,  or  some  similar  instrument  may  be  care- 
fully employed  to  break  up  the  concretion. 

If  the  substance  be  solid,  its  removal  may  be  effected  by 
means  of  a  pair  of  lithotomy  forceps,  or  a  small  lever,  such  as 
obstetricians  make  use  of,  but  reduced  in  size,  or  the  scoop 
employed  to  clear  the  bladder  of  fragments  of  sand  after  the 
operation  of  lithotomy,  (fig.  179,)  or  a  loop  of  wire,  intro- 
duced beyond  the  foreign  body  and  then  drawn  out. 

FIG.  179. 


If  the  object  be  very  large,  it  may  be  drilled  to  fragments 
or  crushed,  as  was  done  by  Dr.  Parker,  of  Canton,  in  the 
case  of  the  large  glass  goblet  introduced  into  the  rectum  of  a 
Chinaman,  reported  by  Dr.  Ruschenberger  in  the  American 
Medical  Journal,  April,  1849 ;  or  the  sphincter  ani  muscle 
may  be  divided,  and  thus  extraction  be  facilitated. 


346      TO   DIMINISH   PAIN   DURING   OPERATIONS. 


OF    THE    MEANS    OF    DIMINISHING    PAIN    DURING 
0  PER  ATIONS. 

Pain  is  at  all  times  an  inconvenience,  and  often  a  positive 
evil  both  to  the  surgeon  and  to  the  patient  who  is  undergoing 
an  operation,  since  it  interferes  with  the  quiescence  which  is 
essential  to  the  performance  of  some  operations  and  of 
portance  in  all ;  and,  moreover,  if  it  be  very  violent  and  p 
tracted,  it  may  produce  such  an  impression  upon  the  patient, 
as  shall  impair  the  success  of  the  operation,  during  its  per- 
formance and  subsequently.  Hence  the  very  general  custom 
of  administering  to  patients  who  are  about  to  submit  to  surgi- 
cal operations  "  some  sweet,  oblivious  antidote,"  for  the  pur- 
pose of  calming  their  apprehensions  of  suffering  and  danger, 
and  to  obtund,  in  a  measure,  their  sensibility  to  pain,  so  that 
the  operation  may  be  performed  with  less  discomfort  to  them- 
selves and  with  more  facility  to  the  surgeon,  than  might 
otherwise  be  possible. 

With  this  view,  it  has  been  usual  to  give  a  dose  of  one  of 
the  preparations  of  opium,  a  short  time  previous  to  the  opera- 
tion, so  that,  when  this  is  being  performed,  the  patient  may 
be  under  the  influence  of  the  anodyne,  not  to  such  a  degree 
as  shall  completely  stupify  him,  but  so  far  as  to  be  calmed 
and  tranquillized  by  it.  The  precise  amount  of  opium  neces- 
sary to  induce  this  condition,  cannot  be  determined  accurately 
and  for  all  cases,  since  different  individuals  are  susceptible  of 
pain  and  of  the  influence  of  narcotics  in  very  different  degrees. 
In  ordinary  cases,  from  forty  to  fifty  drops  of  laudanum  may 
be  administered  to  an  adult,  fifteen  or  twenty  minutes  before 
the  commencement  of  the  operation,  and  this  interval  should 
be  passed  as  quietly  as  possible. 

It  has  long  been  known  that  nitrous  oxids  gas  and  the 
vapours  of  many  vegetable  narcotics  produce,  when  inhaled, 
a  degree  of  insensibility  to  physical  suffering,  and  operations 
have  been  performed  upon  persons  thus  affected;  similar 
results  have  been  attained  by  the  influence  of  animal  mag- 
netism. But  the  importance  of  these  agents  is  slight,  as 
compared  with  that  of  more  recent  discoveries,  —  the  influ- 
ence of  inhalations  of  the  vapour  of  sulphuric  ether  and  of 
chloroform. 


TO   DIMINISH   PAIN    DURING    OPERATIONS.      347 

The  applicability  of  the  vapour  of  Sulphuric  Ether  to  the 
purpose  now  under  consideration,  was  first  established  by 
Dr.  W.  T.  Gr.  Morton,  of  Boston,  on  the  30th  September, 
1846.  (See  Report  of  the  Mass.  Gen.  Hospital,  Jan.  26th, 
1848  —  noticed  in  Am.  Journ.  of  Med.  Sc.,  April,  1848.) 
The  influence  of  Chloroform  in  producing  similar  effects,  was 
first  determined  by  Professor  Simpson,  of  Edinburgh.  (See 
Am.  Journal  of  Pharmacy,  Jan.,  1848.) 

Since  their  effects  became  generally  known,  these  agents 
have  been  employed  to  relieve  pain  in  all  sorts  of  operations, 
and  in  very  many  diseases ;  they  have  been  administered, 
too,  by  the  ignorant  as  well  as  by  the  learned,  and  without 
any  discrimination  of  cases.  It  is  not  at  all  surprising,  there- 
fore, that  in  many  instances  injurious,  and  sometimes  fatal, 
consequences  have  ensued.  It  would  be  out  of  place  to  dis- 
cuss fully,  in  this  volume,  all  the  circumstances  connected 
with  the  use  of  these  agents.  From  the  post-mortem  exami- 
nations which  have  been  had  of  persons  who  have  died  appa- 
rently in  consequence  of  the  inhalation  of  these  vapours,  it 
would  seem  that  they  produce  death  by  asphyxia, — the  lungs, 
the  heart,  the  brain,  having  been  found,  in  these  cases,  to  be 
much  congested,  and  the  blood  dark-coloured  and  more  fluid 
than  usual.  The  legitimate  inference  from  these  facts  is,  that 
these  vapours  should  not  be  resorted  to  in  persons  suffering 
from  congestion  of  these  organs,  or  in  whom  any  important 
disease  of  these  organs  exists.  And  although  it  may  be 
admitted  that  a  sufficient  amount  of  testimony  has  been  accu- 
mulated to  show  that  the  inhalation  of  these  substances  is 
not,  under  proper  regulations  and  in  well-discriminated  cases, 
attended  with  material  danger,  and  that  it  is  even  a  valuable 
aid  to  the  surgeon  in  many  operations,  it  must  also  be 
acknowledged,  on  the  other  hand,  that  we  have  facts  sufficient 
to  prove  that,  without  these  precautions,  and  where  the 
amount  of  pain  to  be  experienced  is  not  very  great,  these 
agents  should  not  be  used.  It  should  be  recollected  that  the 
mere  performance  of  an  operation,  with  comparative  freedom 
from  suffering  to  the  patient  and  with  satisfaction  to  the  sur- 
geon, is  but  one  step  towards  the  cure  of  the  affection  for 
which  the  operation  is  performed  :  the  treatment  of  the  patient 
subsequently  is  a  matter  of  equal  importance  ;  and  with  refer- 
ence to  this  part  of  the  surgeon's  duty,  any  cause  which  -dis- 


348      TO   DIMINISH    PAIN   DURING   OPERATIONS. 

turbs  the  healthy  play  of  important  functions,  whether  it  be 
the  impression  of  too  intense  pain,  or  of  too  powerful  narcotic 
agents,  is  to  be  regarded  as  an  evil. 

The  vapour  of  chloroform  is  probably  less  safe  than  that 
of  sulphuric  ether,  although  it  acts  more  promptly  and  in 
smaller  quantity,  —  six  or  eight  inspirations  being  sometimes 
sufficient.  No  precise  rule  can  be  laid  down  as  to  the  quan- 
tity of  the  fluid,  or  the  period  of  inhalation,  necessary  in 
either  case  to  produce  insensibility  to  pain,  children  and  per- 
sons debilitated  by  disease,  or  other  causes,  being  affected 
much  more  speedily  than  those  in  opposite  circumstances. 
The  vapour  should  be  inhaled  until  the  patient  becomes  insen- 
sible to  pain,  unless  some  unpleasant  effect  be  produced  before 
this  condition  is  attained ;  and  this  insensibility  should  be 
prolonged,  as  may  be  necessary,  by  re-application  of  the 
apparatus  to  the  mouth,  from  time  to  time,  as  the  influence 
of  previous  inhalations  passes  off. 

Many  varieties  of  inhalers  have  been  contrived  for  the 
administration  of  these  vapours,  some  of  them  complicated 
and  expensive ;  the  object  of  all,  however,  is  the  same,— to 
allow  atmospheric  air  to  enter  the  lungs,  loaded  with  the 
vapour  of  ether,  or  of  chloroform.  This  end  may  be  secured 
by  using  either  of  the  inhalers  illustrated  by  the  accompany- 
ing wood-cuts,  as  perfectly  as  by  the  more  complex  apparatus. 
(Figs.  180  and  181.)  Figure  180  represents  a  double-necked 


FIG.  180. 


FIG.  181. 


TO  DIMINISH   PAIN  DURING   OPERATIONS.      349 

bottle  into  which  the  liquid  is  introduced;  through  one  neck 
of  the  bottle,  a  glass  tube  passes,  reaching  below  the  level  of 
the  liquid ;  into  the  other  a  bent  tube  is  inserted,  through 
which  the  patient  breathes.  The  tubes  must  be  tightly  fixed 
in  the  necks  of  the  bottle,  and  the  inspirations  of  the  patient 
must  be  made  through  the  bent  tube,  his  lips  firmly  compress- 
ing the  glass,  the  air  expired  from  the  lungs  passing  out 
through  the  nostrils.  Figure  181  shows  a  common  wide- 
mouthed  bottle,  having  tightly  fixed  in  the  orifice  a  cork 
through  which  the  tubes  enter  the  bottle  as  in  the  other  case. 
But  it  is  not  necessary  to  use  any  apparatus, — a  sponge,  or  a 
piece  of  linen,  wet  with  the  liquid  and  applied  to  the  mouth, 
being  fully  as  efficacious  and  more  safe,  inasmuch  as  a  suffi- 
cient supply  of  atmospheric  air  is  more  certainly  secured. 
The  purest  preparations  only  of  ether  and  chloroform  should 
be  employed.  Before  commencing  the  inhalation  of  the 
vapour,  the  patient  should  be  placed  in  the  position  most 
convenient  for  the  performance  of  the  operation,  whatever  it 
may  be. 

If  any  individual  to  whom  these  agents  have  been  adminis- 
tered should  not  revive  spontaneously,  stimulating  applica- 
tions should  be  made  to  the  surface,  among  the  best  of  which 
is  boiling  water ;  this  should  be  placed  in  a  cup  covered  with 
a  towel,  and  then  the  cup  inverted  upon  the  chest.  (Amer. 
Jour.  Med.  Sc.,  p.  556,  April,  1848.)  Artificial  inspiration 
should  be  resorted  to,  if  other  means  fail. 

The  reader  will  find  details  as  to  the  mode  of  preparing 
ether  and  chloroform  in  the  Am.  Journ.  of  Pharmacy,  for 
Oct.,  1847,  and  January  and  April,  1848.  Numerous  articles 
relating  to  their  employment  are  contained  in  the  Am.  Journ. 
of  Med.  Sc.  for  1847-8,  to  which  reference  should  be  made 
by  those  who  may  be  disposed  to  test  the  action  of  these 
agents.  Besides  these  publications,  the  author  would  recom- 
mend attention  to  the  report  of  Dr.  Isaac  Parrish,  of  this 
city,  to  the  College  of  Physicians,  published  in  the  "  Transac- 
tions" of  that  body ;  to  the  essays  of  Dr.  Warren,  Dr.  Simp- 
son, and  Mr.  Miller ;  that  of  the  latter  being  appended  to  the 
last  edition  of  his  Principles  of  Surgery. 

30 


APPENDIX  OF  FORMULA. 


THE  following  list  of  formulae  will  be  found  to  contain 
many  which  have  been  proved  to  be  valuable  in  answering 
the  indications  for  which  they  are  directed. 


LOTIONS. 

I.    ASTRINGENT    LOTIONS. 

1.  Wash  for  secondary  venereal  ulcers,  particularly  of  the  throat — 

R.     Cupri  sulphatis,  9ij, 
Pulv.  cinchonas,  ^ss, 
Aquae  fluvialis,  f^viij. 
M.  ft.  lot.— Dr.  Physick. 

2.  R.     Tinct.  myrrhae,  fjj— f£ss, 

Aquae  fluvial.,  f^viij. 
M.  ft.  lot. 

3.  R.     Creasotae,  gtts.  xx — gtts.  1, 

Aquae  fluvial.,  f^vj. 
M.  ft.  lot. 

4.  R.     Tannin  9j, 

Spt.  vini  gallici.,  f^ss, 
Mist.  Camphorae,  f^vss. 
M.  ft.  lot. — For  salivation,  spongy  gums,  &c. 

5.  R.     Sodii  chlorid.,  (sol.) 

Tinet.  myrrhas,  aa  fjss, 
Aquae  fluvial.,  f^iv. 
M.  ft.  lot.  —  Uses  the  same  as  the  last. 

(350) 


APPENDIX.  351 


II.    STIMULATING    LOTIONS. 

6.  R.     Acidi  nitrici,  f3J — f^ij, 

Aquas  fluvial.,  f^viij, 
Aquae  rosae,  f^j. 
M.  ft.  lot. 

7.  R.     Ammoniae  muriat.,  £j — 3y? 

Aquae  fluvial.,  f^viij, 
Tinct.  opii,  f^j. 
M.  ft.  lot.  —  For  painful  indolent  ulcers. 

8.  R.     Acid,  cyanhydrici,  f£j, 

Mucilag.  acaciae,  f^viij, 
M.  ft.  lot.  —  To  relieve  the  itching  in  prurigo. 

9.  R.     Hydrarg.  chlorid.  mit.,  $\jj 

Liquoris  calcis,  ^viij. 
M.  ft.  lot.  —  «  The  black  wash."  ' 

10.  R.     Hydrarg.  bi-chlorid.,  grs.  x — 9j, 

Liquoris  calcis,  ^viij. 
M.  ft.  lot. 

11.  R.     Spt.  vini  rectificati, 

Tinct.  camphorae,  aa  f^iijss, 

Liquor,  plumbi,  f^j. 

M.  ft.  lot.  —  To  be  rubbed  upon  the  part  several  times  daily,  oc- 
casionally suspending  it.  For  indolent  fibrous  tumours  of  the 
breast.  —  Brodie. 

12.  R.     lodini  9j, 

Potassii  iodid.,  3SS> 
Aquae  fluvial,  f^viij 

M.  ft.  lot.  —  For  application  to  scrofulous  and  other  indolent 
tumours. 


III.   EVAPORATING    AND     REFRIGERANT    LOTIONS. 

13.   R.     Ammoniae  mur.,  3J> 
Potassae  nitrat.7  3y> 


352  APPENDIX. 

Vinegar,  fpj, 
Aquae  fluvial.,  f^x. 
M.  ft.  lot.  —  Schmucker's  frigorific  mixture. 

14.  R.     JEtheris  sulphuric. 

Alcohol, 

Aquae  plumbi,  aa  f^j. 
M.  ft.  lot. 

15.  R.     Sodii  chloridi, 

Potassae  nitratis, 
Ammoniae  muriat,  aa  Jij, 
Aquae  fluvial.,  q.  s.  ad  mist,  solvend. 
M.  ft.  lot.  —  Druitt. 

16.  R.     Spt.  vini  rectif.,  f£j, 

Aquas  fluvial.,  f^vij. 
M.  ft.  lot. 


CERATES. 

17.  R.     Resinae,  gj, 

Cer.  flav.,  ^ij, 
Adipis,  ^v. 
M.  ft.  cerat.  —  For  burns.  —  Physick. 

18.  R.     Cerat.  plumbi,  s'acet., 

Cerat.  simplicis,  aa  ^ss, 
Hydrarg.  chlor.  mit., 
Pulv.  opii,  aa  5J- 
M.  ft.  cerat.  —  For  burns,  painful  ulcers,  &c. 

19.  R.     Unguent,  hydrarg.  nit.,  5j, 

Cerat.  simplicis,  Jnj — ^ss. 
M.  ft.  cerat.  —  For  sore  nipples,  &c. 

20.  R.     Pulv.  camphorae,  9j — 3j; 

Cerat.  simpl.,  ^j. 
M.  ft.  cerat.  —  A  stimulating  salve. 

21.  R.     Hydrarg.  chlorid.  mit.,  grs.  vj, 

Pulv.  opii,  grs.  x, 
Cerat.  simpl.,  3ij- 
M.  ft.  cerat.  —  For  indurated  chancres. 


APPENDIX.  353 

22.   R.     Acid,  hydrocyanic,  gtts.  xx, 

Cerat.  simpl.,  ^ij. 
M.  ft.  cerat.  —  For  papular  eruptions  attended  with  itching. 


23.  R.     Creosotae,  gtts.  xx, 
Cerat.  simpl.,  ^ij, 
Zinci  oxid.,  3J- 
M.  ft.  cerat.  —  For  scaly  eruptions. 


OINTMENTS. 


24.  R.     Potassae  carh.,  gss, 

Aquae  rosae,  f^j, 
Hydrarg.  sulph.  rubr.,  ^j, 
01.  bergam.,  f^ss, 
Fl.  sulphuris, 
Adipis,  aa  ^ix. 

M.  ft.  unguent.  —  Bateman's  aromatic  sulphur  ointment,  for 
itch,  &c. 

25.  R.     Picis  liquid,  fgj, 

Salt  butter,  gij, 
Melt  together,  and  add  of 

Common  potashes,  3j, 
Grafe's  itch  ointment. 

26.  R.     Unguent,  hydrarg.  fort.,  gj, 

Antimon.  et  potass,  tart.,  5J> 

lodini,  grs.  x — xv. 

M.  ft.  unguent. — To  be  rubbed  upon  the  part  daily,  until  it  pus- 
tulates. For  chronic  glandular  tumours,  old  indurated  buboes,  &c. — 
H.  Johnson. 

27.  R.     Morphias  acetat.  grs.,  vj, 

Pulv.  gallae,  3J, 
Unguent,  stramonii,  ^j. 
M.  ft.  unguent. — For  haemorrhoids. — Harlan. 

28.  R.     Sodse  bi-carb.,  Jj, 

Adipis,  |j, 
Pulv.  opii,  9j. 

M.  ft.  unguent. — For  lichen,  prurigo,  &c. 
30* 


354  APPENDIX. 


LINIMENTS. 

29.  R.     01.  tiglii.,  fjss, 

01.  cinnamomi,  f£j, 
01.  olivae,  fgj, 
Lin.  cantharid,  f§ij. 
M.  ft.  liniment. — for  neuralgia. — Prof.  Jackson. 

30.  R.     01.  olivse, 

Alcohol  aa,  fgj, 
Tr.  camphorae,  f^ss, 
Aquae  ammoniae,  f^j. 
M.  ft.  liniment. — For  indurated  breasts. 

31.  R.     01.  terebinth, 

01.  lini  aa  Oss, 
01.  succini, 
01.  juniperi  aa  f^iv, 
Petrol.  Barbadensis,  ^iij, 
Petrol.  American,  ^j, 

M.— "The  British  Oil."     To  be  used  diluted  with  olive  oil,  or 
lard,  as  a  stimulating  liniment,  or  ointment. 


INDEX. 


ABDOMEN,  bandage  for,  93. 
Acids,  counter  irritation  by,  273. 

cauterization  by,  285. 
Actual  cautery,  284. 
Acupuncture,  278. 
Adhesive  plasters,  34. 
>2Ether  347. 

Air-passages,  catbeterism  of,  326. 
Ammonia,  as  a  counter-irritant,  272. 
Anaesthetics,  342. 
Anchylosis,  relief  of  partial,  233. 
Aneurism-needles,  297. 
Apparatus  for  treatment  of  fractures,  108. 

dislocations,  210. 

the  immovable,  of  Dieffenbach,  115. 
Laugier,  114. 
Larrey,  112. 
Seutin,  113. 
Velpeau,  114. 

of  dressings,  29. 

of  instruments,  26. 
Arteries,  cauterization  of,  284. 


ligature  of,  294. 

plugging  of,  293. 

torsion  of,  204. 
Arteriotomy,  257. 
Artery,  wound  of,  ia  bleeding,  255. 


Bandages,  and  their  application,  65. 
Bandages,  compound,  72. 


Bandage,  the  simple,  or  the  roller,  65. 

winding  of  the,  66. 

application  of  the,  66. 

the  circular,  67. 

the  compressing,  70. 

the  crossed,  69. 

the  dividing,  70. 

the  expelling,  71. 

the  invaginated,  72. 

the  knotted,  71. 

the  laced,  74. 

the  recurrent,  70. 

the  retaining,  7L 

the  spica,  70. 

the  spiral,  67. 

the  spiral  reversed,  68. 

the  split,  or  tailed,  73. 

the  sheath,  74. 

the  suspensory,  74. 
Bandaging,  Mayor's  system  of,  75. 
Barton's  bandage  for  lower  jaw,  123. 

bran-dressing,  206. 

fracture  of  the  radius,  151. 
Baynton's  treatment  of  ulcers,  36. 
Bathing,  57. 

Baud  en's  dry  suture,  308. 
Bell's  inclined  plane,  166. 
Belloc's  instrument  for  epistaxis,  300. 
Bleeding,  operations  for  general,  241. 
for  topical,  258. 

from  the  ankle,  250. 

from  the  arm,  242. 

(355) 


356 


INDEX. 


Bleeding,  from  the  external  jugular,  251. 

from  the  hand,  250. 

from  the  temporal  artery,  257. 

accidents  attending,  253. 
Blisters,  268. 

Beyer's  apparatus  for  fracture  of  thigh,  180. 
Bond's  splint  for  fractured  radius,  154. 

gullet-forceps,  338. 

gullet-hook,  338. 
-dressing,  206. 
Breast,  bandages  for  the,  90,  91. 
Brown's  bandage  for  fracture  of  clavicle,  131. 

Canquoin's  caustic,  275. 
Carpus,  bandages  for  the,  102. 

dislocations  of  the,  221. 

fractures  of,  159. 
Catheterism  of  the  air  passages,  326. 

of  the  eustachian  tube,  315. 

of  the  lachrymal  passages,  312. 

of  the  large  intestine,  325. 

of  the  oesophagus,  316. 

of  the  urethra  of  the  female,  324. 

of  the  male,  318. 
Cerates,  47,  352. 
Charpie,  29. 

Chest,  bandages  for  the,  88. 
Chin,  bandages  for  the,  81. 
Chlorides  of  lime  and  soda,  62. 
Chloride  of  zinc,  275. 
Chloroform,  347. 
Clavicle,  dislocations  of  the,  213. 

fractures  of  the,  128. 
Clinical  frame,  119. 
Clove-hitch,  222. 
Collodion,  38. 

Colics'  fracture  of  the  radius,  151. 
Compresses,  32. 
Condyles  of  humerus,  fracture  of,  142. 

os  femoris,  fracture  of,  186. 
Coronoid  process  of  ulna,  fracture  of,  155. 
Cotton,  31. 
Croton  oil,  271. 
Cupping,  258. 
Cutaneous  irritation,  266. 

by  rubefacients,  266. 

by  suppurative  agents,  273. 

by  vesicants,  268. 


Demi-gauntlet,  102. 

Desault's  apparatus  for  fracture  of  olecranon, 
158. 
of  patella,  192. 


Desault's  apparatus  for  fractures  of  the  thigh, 

172. 

Disinfecting  agents,  62. 
Dislocations  of  bones  of  the  foot,  231. 

hand,  221. 

lower  extremity,  224. 

trunk,  213. 

Tipper  extremity,  215. 

clavicle,  213. 

lower  jaw,  212. 

compound,  232. 
Douche,  54. 
Dressing,  general  rules  for,  49. 

apparatus  of,  29. 

instruments,  26. 

Eighteen-tailed  bandage,  104. 
Electric-moxa,  278. 
Electro-puncture,  279. 
Epididymitis,  Fricke's  treatment  of,  37. 
Eustachian  tube,  catheterism  of,  315. 
Extending  band,  adhesive  strips  for,  177. 

gaiter  for,  174. 

handkerchief  for,  177. 

Face,  bandages  for,  81. 
Femur,  fractures  of,  163. 
Fibula,  dislocations  of,  230. 

fractures  of,  204. 
Fingers,  bandages  for,  102. 

dislocations  of,  221. 

fractures  of,  160. 
Fore-arm,  bandages  for,  100. 

dislocations  of,  218. 

fractures  of,  148. 
Foreign  bodies,  removal  of,  333. 

from  eye,  333. 

from  nose,  334. 

from  ear,  335. 

from  pharynx  and  oesophagus,  336. 

from  larynx  and  trachea,  340. 

from  urethra,  343. 

from  vagina,  344. 

from  rectum,  344. 
Fox's  clavicle  apparatus,  129. 
Fractures,  general  considerations  on,  108. 

immovable  apparatus  for,  112. 

hyponarthecia  for,  115. 

Jenk's  apparatus  for,  120. 

of  the  bones  of  the  face,  121. 
of  the  foot,  208. 
of  the  fore-arm,  148. 
of  the  hand,  159. 


INDEX. 


357 


Fractures  of  the  bones  of  the  head,  121. 

of  the  leg,  197. 

of  the  pelvis,  126. 

of  the  shoulder,  128. 

of  the  trunk,  124. 

of  the  vertebral  column,  124. 
of  the  clavicle,  128. 
of  the  fibula,  204. 
of  the  humerus,  138. 
of  the  lower  jaw,  121. 
of  the  os  calcis,  208. 
of  the  os  femoris,  163. 
of  the  patella,  190. 
of  the  radius,  151. 
of  the  ribs,  125. 
of  the  scapula,  133. 
of  the  sternum,  125. 

of  the  tibia,  204. 

of  the  ulna,  155. 
Fracture-bed,  117. 
Fracture-box,  198. 
Fumigations,  61. 

Gaiter,  laced,  107. 

for  extension  in  fracture  of  thigh,  174. 
Gauntlet,  102. 

Gerdy's  bandage  for  fracture  of  patella,  192. 
Gibson's  bandage  for  fracture  of  lower  jaw, 

122. 
Gibson's  modification  of  Hagedorn's  splint, 

183. 

Good's  splint,  155. 
Granville's  lotions,  272. 
Groin,  bandages  for  the,  94. 
Guillou's  novel  method  of  treating  fracture 

of  clavicle,  132. 
Gun-cotton,  a  solution  of,  for  adhesive  strips, 

304. 

Hand,  bandages  for,  102. 

dislocations  of  bones  of,  221. 

fractures  of  bones  of,  159. 
Hare-lip,  twisted  suture  for,  307. 
Head,  bandages  for,  77. 

fractures  of  bones  of,  121. 
Haemorrhage,  arrest  of,  282. 

by  astringents,  282. 

by  cauterization,  284. 

by  cold  applications,  282. 

by  the  ligature,  294. 

by  matico,  283. 

by  plugging,  293. 


Haemorrhage,  arrest  of,  by  pressure  with  the 

hand,  286. 
Hemorrhage,  arrest  of,  by  torsion,  294. 

by  the  tourniquet,  288. 

from  the  nose,  299. 

from  the  rectum,  301. 
Hip-joint,  dislocations  of,  224. 
Humerus,  dislocations  of,  215. 

fractures  of,  138. 


thigh, 


Immovable  apparatus  for  fractures,  112. 
Inclined  plane  for  fractures  of  the 
166. 

for  fractures  of  the  leg,  202. 
Injections,  modes  of  administering,  327. 

of  lachrymal  duct,  331. 

by  the  rectum,  327. 

of  the  urethra,  329. 

of  the  uterus,  329. 

of  the  vagina,  329. 
Instruments  for  the  pocket-case,  25. 
Invaginated  bandage  for  the  lip,  84. 

for  longitudinal  wounds,  309. 

for  transverse  wounds,  310. 
Irrigation,  52. 
Isinglass-plaster,  38. 
Issues,  276. 


Jarvis's  Adjuster,  219. 
Jaw,  bandages  for,  79. 

dislocations  of  lower,  212. 
fractures  of  lower,  121. 
Jenks's  apparatus,  120. 
Jorg's  apparatus  for  wry-neck,  87. 
Jugular  vein,  bleeding  from,  251. 
Junks,  treatment  of  fractures  of  the  leg  with, 

197. 
Junk-bags  for  fracture  of  thigh,  174. 

Knee,  bandages  for  the,  105. 
dislocations  of  the,  230. 
fractures  of  the,  190. 

Lachrymal  duct,  injection  of,  331. 
Lancets  for  bleeding,  245. 
Leeches,  artificial,  265. 
Leeches,  preservation  of,  263. 
Leeching,  261. 
Leg,  bandages  for,  106. 

dislocations  of,  229. 

fractures  of,  197. 


358 


INDEX. 


Ligature  for  the  arrest  of  haemorrhage,  294. 
Liniments,  47,  354.  «, 

Lint,  preparation  and  uses  of,  29. 
Lotions,  46,  350. 


M.  Le  Doyen's  disinfectant,  63. 
Mayor  and  Sauter,  clinical  frame  of,  119. 
hyponarthecia  for  the  arm  of,  150. 

for  the  leg  of,  206. 
Moxa,  preparation  and  application  of  the, 
275. 


Neck  and  axilla,  bandages  for  the,  86, 90, 99. 
Nitrate  of  silver,  274. 
Nose,  bandages  for  the,  82. 

fracture  of  the  bones  of  the,  121. 
Nostrils,  arrest  of  bleeding  from  the,  299. 


Ointments,  47,  353. 


Patella,  dislocations  of  the,  229. 
fractures  of  the,  190. v 

Penis,  bandages  for  the,  98,  324. 

Pennsylvania  Hospital,  treatment  of  frac- 
tures of  clavicle  in  the,  130. 

Pennsylvania  Hospital,  treatment  of  frac- 
tures of  thigh  in  the,  173. 

Pennsylvania  Hospital,  treatment  of  frac- 
ture of  leg  in  the,  197. 

Pelvis,  bandages  for,  94. 
dislocations  of,  213. 
fractures  of,  126. 

Phlebotomy,  241. 

Physick's  splints  for  fracture  of  thigh,  173. 

Plasters  38. 

Potassa,  274. 

Poultices,  39. 

Pulleys  for  reduction  of  dislocations,  217. 

Purse  of  Pibrac  for  the  tongue,  84. 


Radius,  dislocations  of  the,  220. 

fractures  of  the,  151. 
Ribs,  dislocations  of  the,  213. 

fractures  of  the,  125. 
Roller,  the,  65. 


Sailor's  knot,  296. 

Scapula,  fractures  of  the,  133. 


Scultetus's  bandage,  78. 
Setons,  276. 
Seton-needle,  276. 
Sinapisms,  267. 
Spanish  windlass,  290. 
Splints  of  Amesbury,  169,184. 

Bache,  179. 

Barton,  152. 

Bond,  154. 

Boyer,  180. 

Desault,  158, 173, 192. 

Dupuytren,  151,  205. 

Fergusson,  201. 

Gibson,  183. 

Good,  155. 

Hagedorn,  183. 

Hays,  155. 

Hutcbinson,  201. 

Kimball,182. 

Liston,  181,  203. 

Lonsdale,  124, 140, 149, 193. 

Mayo,  146. 

Mutter,  233. 

Nelaton,  153. 

Neville,  198. 

Physick,  173. 

Smith,  N.R.,  171. 

Sponge,  preparation  and  uses  of  the,  47. 
Sponge-tAit,  34. 
Spongio-Piline,  45. 
Sternum,  fractures  of  the,  125. 
Stomach,  catheterism  of  the,  316. 
Suture,  the  continued,  305. 

the  dry,  308. 

the  interrupted,  305. 

the  quilled,  306. 
'  the  twisted,  307. 


Tarsus,  dislocations  of  the  bones  of,  231. 

fractures  of  the  bones  of,  208. 
Tartar  emetic,  273. 
Torsion,  294. 
Tourniquet,  288. 
Tow,  31. 


Urethra,  catheterism  of  the,  318. 
injections  of  the,  329. 


Vaccination,  280. 


INDEX. 


359 


Vaccine  virus,  preservation  of,  280. 
Vagina,  injections  by  the,  329. 
Vapours  of  ether  and  chloroform,  346. 
Venesection,  241. 

Veins  of  the  arm,  anatomy  of  the,  242. 
Vertebrae,  fractures  of  the,  124. 

dislocations  of  the,  213. 
Vesicants,  268. 
Vidal's  spring-suture,  309. 


Vienna  paste,  274. 

Wounds,  means  of  promoting  the  closure  of^ 

303. 

dressing  of,  302. 
Water,  applications  of,  to  surgical  purposes, 

52. 

Appendix  of  formula,  350. 


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STOMACH.  In  one  neat  octavo  volume,  extra  cloth.  (Now  Ready.) 

BUCKLER  (T.  H.).  M.D. — ON  THE  ETIOLOGY,  PATHOLOGY,  AND  TREATMENT  OF  FIBBO-BRONCHITIS 
AND  RHEUMATIC  PNEUNOMiA.  In  one  handsome  octavo  volume,  extra  cloth. 

BUSIINAN  (J.  S.),  M.  D.— PRINCIPLES  OF  ANIMAL  AND  VEGETABLE  PHYSIOLOGY.  A  Popular 
Treatise  on  the  Functions  and  Phenomena  of  Organic  Life.  In  one  handsome  royal  12mo. 
volume,  extra  cloth,  with  numerous  illustrations. 


BLOOD  AND  URINE  (M ANUALS  ON).— BY  JOHN  WILLIAM  GRIFFITH.  G.  OWEN  REESE,  AND 
ALFRED  MARKWICK.    One  thick  volume,  royal  12mo.,  extra  cloth,  with  plates.    460  pages. 


BRODIE  (SIR  BENJAMIN  C.),  M.  D. — CLINICAL  LECTURES  ON  SURGERY.    One  vol.,  8vo.,  cloth. 
350  pages. 


BIRD  (GOLDING),  M. D.— URINARY  DEPOSITS:  THEIR  DIAGNOSIS.  PATHOLOGY,  AND  THERAPEUTI- 
CAL INDICATIONS.  A  new  and  enlarged  American,  from  the  last  improved  London  edition. 
With  over  sixty  illustrations.  In  one  royal  12mo.  volume,  extra  cloth. 

B ARTLETT  (ELISII A),  M.  D. — THE  HISTORY,  DIAGNOSIS,  AND  TREATMENT  OF  THE  FEVERS  OF  THE 
UNITED  STATES.  Fourth  edition,  revised,  with  Additions  by  Alonzo  Clark,  M.D.  In  one 
handsome  octavo  volume.  (Nearly  Ready.) 


BOWMAN  (JOHN  E.%  M.D. — PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.  Second  American, 
from  the  third  and  revised  London  edition.  In  one  neat  volume,  royal  12mo.,  with  nume- 
rous illustrations.  288  pages. 

BOWMAN  (JOHN  E.),  M.D. — INTRODUCTION  TO  PRACTICAL  CHEMISTRY,  INCLUDING  ANALYSIS. 
Second  American,  from  the  second  and  revised  English  edition.  With  numerous  illustra- 
tions. In  one  neat  volume,  royal  12mo.  350  pages.  (Now  Ready.) 

BARLOW  (GEORGE  H.),  M.D. — A  MANUAL  OF  THE  PRACTICE  OF  MEDICINE.  With  Additions 
by  D.  F.  Condie,  M.D.  In  one  handsome  octavo  volume,  leather,  of  600  pages.  (Now 
Ready.) 


CURLING  (T.  B.),  F.  R.  S. — A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  TESTIS,  SPERMATIC  CORD, 
AND  SCROTUM.  Second  American,  from  the  second  and  enlarged  English  edition.  With 
numerous  illustrations.  In  one  handsome  octavo  volume,  extra  cloth.  (Now  Ready.) 

COLOMBAT  DE  L'ISERE. — A  TREATISE  ox  THE  DISEASES  OF  FEMVLES,  and  on  the  Special 
Hygiene  of  their  Sex.  Translated,  with  many  Notes  and  Additions,  by  C.  D.  Meier.?,  M.  D. 
Second  edition,  revised  and  improved.  In  one  large  volume,  octavo,  with  numerous  wood- 
cuts. 720  pages. 

COPLAND  (JAMES),  M.D.— OF  TUT:  CAUSES,  NATURE,  AND  TREATMENT  OF  PALPY  AND  APOPT.KTY, 
nnd  of  the  Forms,  Seats,  Complications,  and  Morbid  Relations  of  Paralytic  and  Apoplectic 
Diseases.  In  one  volume,  royal  12mo.,  extra  cloth.  026  pages 


BLANCIIARD  &  LEA'S  MEDICAL  PUBLICATIONS.  3 

CARSON'  (JOSEPH),  M.  D.— SYNOPSIS  OF  THE  COURSE  OP  LECTURES  ON  MATERIA  MEDICA  AND 
PHARMACY,  delivered  in  the  University  of  Pennsylvania.  Second  edition,  revised.  In  one 
very  neat  octavo  volume,  of  208  pages. 


CARPENTER  (WILLIAM  B.),  M. D.— PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with  their  chief 
applications  to  Psychology,  Pathology,  Therapeutics,  Hygiene,  and  Forensic  Medicine.  A 
new  American,  from  the  last  and  revised  London  edition.  With  nearly  three  hundred 
illustrations.  Edited,  with  Additions,  by  Francis  Gurney  Smith,  M.D.,  Professor  of  the 
Institutes  of  Medicine  in  the  Pennsylvania  Medical  College,  etc.  In  one  very  large  and 
}><>autiful  octavo  volume,  of  about  900  large  pages,  handsomely  printed,  and  strongly 
bound  in  leather,  with  raised  bands.  (Just  Issued.) 


CARPENTER  (WILLIAM  B.),  M.  D.— PRINCIPLES  OF  COMPARATIVE  PHYSIOLOGY.  New  Ameri- 
can, from  the  fourth  and  revised  London  edition.  In  one  large  and  handsome  octavo 
volume,  with  over  three  hundred  beautiful  illustrations. 


CARPENTER  (WILLIAM  B.),  M.D. — THE  MICROSCOPE  AND  ITS  REVELATIONS.  With  an  Ap- 
pendix containing  the  Applications  of  the  Microscope  to  Clinical  Medicine,  by  F.  G.  Smith, 
M.D.  With  434  beautiful  wood  engravings.  In  one  large  and  very  handsome  octavo 
volume  of  724  pages,  extra  cloth  or  leather.  (Now  Heady.) 


CARPENTER  (WILLIAM  B.),  M.  D.— ELEMENTS  (OR  MANUAL)  OF  PHYSIOLOGY,  INCLUDING  PHY- 
SIOLOGICAL ANATOMY.  Second  American,  from  a  new  and  revised  London  edition.  With 
one  hundred  and  ninety  illustrations.  In  one  very  handsome  octavo  volume. 

CARPENTER  (WILLIAM  B.),  M.  B.— PRINCIPLES  OF  GENERAL  PHYSIOLOGY,  INCLUDING  ORGANIC 
CHEMISTRY  AND  HISTOLOGY.  With  a  General  Sketch  of  the  Vegetable  and  Animal  Kingdom. 
In  one  large  and  handsome  octavo  volume,  with  several  hundred  illustrations.  (Preparing.) 


CARPENTER  (WILLIAM  B.),  M.D.— A  PRIZE  ESSAY  ON  THE  USE  OF  ALCOHOLIC  LIQUORS  IN 
HEALTH  AND  DISEASE.  New  edition,  with  a  Preface  by  D.  F.  Condie,  M.D.,  and  explanations 
of  scientific  words.  In  one  neat  12mo.  volume. 


CIIRISTISON  (ROBERT),  M.D.— A  DISPENSATORY;  or,  Commentary  on  the  Pharmacopoeias 
of  Great  Britain  and  the  United  States:  comprising  the  Natural  History,  Description, 
Chemistry,  Pharmacy,  Actions,  Uses,  and  Doses  of  the  Articles  of  the  Materia  Medica. 
Second  edition,  revised  and  improved,  with  a  Supplement  containing  the  most  important 
New  Remedies.  With  copious  Additions,  and  two  hundred  and  thirteen  large  wood- 
engravings.  By  R.  Eglesfeld  Griffith,  M.D.  In  one  very  large  and  handsome  octavo 
volume,  of  over  1000  pages. 


CHELIUS  (J.  M.),  M.  D.— A  SYSTEM  OF  SURGERY.  Translated  from  the  German,  and  accom- 
panied with  additional  Notes  and  References,  by  John  F.  South.  Complete  in  three  very 
large  octavo  volumes,  of  nearly  2200  pages,  strongly  bound,  with  raised  bands  and  double 
titles. 


CONDTE  (D.  F.).  M.  D. — A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN.    Fourth  edition, 
revised  and  augmented.    In  one  large  volume,  8vo.,  of  nearly  750  pages. 


COOPER  (BRANSBY  B.),  M.  D.— LECTURES  ON  THE  PRINCIPLES  AND  PRACTICE  OP  SURGERT.    In 
one  very  large  octavo  volume,  of  750  pages. 


COOPER  (SIR  ASTLEY  P.)  — A  TREATISE  ox  DISLOCATIONS  AND  FRACTURES  OF  THE  JOINTS. 
Edited  by  Bransby  B.  Cooper,  F.R.S.,  etc.  With  additional  Observations  by  Prof.  J.  C. 
Warren.  A  new  American  edition.  In  one  octavo  volume,  with  numerous  wood-cuts. 


4  BLANCHARD  &  LEA'S  MEDICAL  PUBLICATIONS. 

COOPER  (SIR  ASTLEY  P.)— ON  THE  STRUCTURE  AND  DISEASES  OF  THE  TESTIS,  AND  ON  THB 
THYMUS  GLAND.    One  vol.  imperial  8vo.,  with  177  figures,  on  29  platea. 


COOPER  (SIR  ASTLEY  P.)— ON  THE  ANATOMY  AND  DISEASES  OF  THE  BREAST,  with  twenty-five 
Miscellaneous  and  Surgical  Papers.  One  large  volume,  imperial  Svo.,  with  252  figures,  on 
36  plates, 


SL: 


CHURCHILL  (FLEETWOOD),  M.D. — ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.    A  new 
American,  from  the  last  and  improved  English  edition.     Edited,  with  Notes  and  Additions, 
D.  Francis  Condie,  M.  D.,  author  of  a  "  Practical  Treatise  on  the  Diseases  of  Children," 
With  139  illustrations.    In  one  very  handsome  octavo  volume,  510  pages. 


CHURCHILL  (FLEETWOOD),  M.D.  —  ON  THE  DISEASES  OF  INFANTS  AND  CHILDREN.  Second 
American  edition,  revised  and  enlarged  by  the  author.  With  Additions  by  W.  V.  Keating, 
M.  D.  In  one  large  and  handsome  volume  of  700  pages.  (Now  Heady.) 


CHURCHILL  (FLEETWOOD),  M.D.— ESSAYS  ON  THE  PUERPERAL  FEVER,  AND  OTHER  DISEASES 
PECULIAR  TO  WOMEN.  Selected  from  the  writings  of  British  authors  previous  to  the  close 
of  the  eighteenth  century.  In  one  neat  octavo  volume,  of  about  450  pages. 


CHURCHILL  (FLEETWOOD),  M.D.— ON  THE  DISEASES  OF  WOMEN;  including  those  of  Preg- 
nancy and  Childbed.  A  new  American  edition,  revised  by  the  author.  With  Notes  and 
Additions,  by  D.  Francis  Condie,  M.D.,  author  of  a  "Practical  Treatise  on  the  Diseases  of 
Children."  In  one  large  and  handsome  octavo  volume,  with  wood-cuts.  (Nearly  Heady.) 


DEWEES  (W.  P.),  M.  D.— A  COMPREHENSIVE  SYSTEM  OF  MIDWIFERY.  Illustrated  by  occasional 
Cases  and  many  Engravings.  Twelfth  edition,  with  the  Author's  last  Improvements  and 
Corrections.  In  one  octavo  volume,  of  600  pages. 


DEWEES  (W.  P.),  M.  D.— A  TREATISE  ON  THE  PHYSICAL  AND  MEDICAL  TREATMENT  OF  CHILDREN. 
Tenth  edition.    In  one  volume,  octavo,  548  pages. 


DEWEES  (W.  P.),  M.  D. — A  TREATISE  ON  THE  DISEASES  OF  FEMALES.    Tenth  edition.    In  one 
volume,  octavo,  532  pages,  with  plates. 


DRUITT  (ROBERT),  M.R.C.  S. — THE  PRINCIPLES  AXD  PRACTICE  OF  MODERN  SURGERY.  A  new 
American,  from  the  improved  London  edition.  Edited  by  F.  W.  Sargent,  M.  D.,  author  of 
"  Minor  Surgery,"  &c.  Illustrated  with  one  hundred  and  ninety-three  wood-engravings. 
In  one  very  handsomely-printed  octavo  volume,  of  576  large  pages. 


DUNGLISON,  FORBES,  TWEEDTE,  AND  CONOLLY.— THE  CYCLOPEDIA  OF  PRACTICAL  MEDI- 
CINE: comprising  Treatises  on  the  Nature  and  Treatment  of  Diseases.  Materia  Medica  and 
Therapeutics,  Diseases  of  Women  and  Children,  Medical  Jurisprudence,  &c.  &c.  In  four 
large  super-royal  octavo  volumes,  of  3254  double-columned  pages,  strongly  and  hand- 
somely bound. 

***  This  work  contains  no  less  than  four  hundred  and  eighteen  distinct  treatises,  contri- 
buted by  sixty-eight  distinguished  physicians. 

TUNGLISON  (ROBLEY),  M.  D.  —  MEDICAL  LEXICON;  a  Dictionary  of  Mmlical  Science,  con- 
taining a  concise  Explanation  of  the  various  Subjects  and  Terms  of  Physiology,  Pathology, 
Hygiene,  Therapeutics,  Pharmacology,  Obstetrics,  Medical  Jurisprudence,  &c..  With  the 
French  and  other  Synonymes;  Notices  of  Climate  and  of  cclebrntod  Miner.il  Waters;  For- 
mula for  varkms  Officinal,  Empirical,  and  Dietetic  Preparations.  Ac.  Thirteenth  edition, 
revised.  In  one  very  thick  octavo  volume,  of  over  900  large  double-columned  pages, 
strongly  bound  in  leather,  with  raised  bands.  (Just  Issued.) 


BLANCIIARD  &  LEA'S  MEDICAL  PUBLICATIONS.  5 

DUNGLISON  (ROBLEY),  M.  D.— THE  PRACTICE  OF  MEDICINE.    A  Treatise  on  Special  Pathology 
and  Therapeutics.    Third  edition.    In  two  large  octavo  volumes,  of  1500  pages. 


DUNGLISON  (ROBLEY),  M.  D.— GENERAL  THERAPEUTICS  AND  MATERIA  MEDICA;  adapted  for  a 
Medical  Text-book.  Fifth  edition,  much  improved.  With  one  hundred  and  eighty-seven 
illustrations.  In  two  large  and  handsomely  printed  octavo  volumes,  of  about  1100  pages. 
(Just  Issued.) 

DUNGLISON  (ROBLEY),  M.  D. — NEW  REMEDIES,  WITH  FORMULA  FOR  THEIR  PREPARATION  AND 
ADMINISTRATION.  Seventh  Edition,  with  extensive  Additions.  In  one  very  large  octavo 
volume,  of  770  pages.  (Now  Heady.) 

DUNGLISON  (ROBLEY),  M.D.— HUMAN  PHYSIOLOGY.  Eighth  edition.  Thoroughly  revised 
and  extensively  modified  and  enlarged,  with  over  500  illustrations.  In  two  large  and 
handsomely  printed  octavo  volumes,  containing  about  1500  pages. 


DICKSON  (S.  II.)j  M. D. — ELEMENTS  OP  MEDICINE:  a  Compendious  Yiew  of  Pathology  and 
Therapeutics,  or  the  History  and  Treatment  of  Diseases,  lu  one  large  and  handsome 
octavo  volume  of  750  pages,  leather.  (Just  Issued.) 


DE  JONGH  (L.  J.),  M.  D. — THE  THREE  KINDS  OP  COD-LIVER  OIL.  comparatively  considered,  with 
their  Chemical  and  Therapeutic  Properties.  Translated,  with  an  Appendix  and  Cases,  by 
Edward  Carey,  M.  D.  To  which  is  added  an  article  on  the  subject  from. "  Dunglison  on 
New  Remedies."  In  one  small  12mo.  volume,  extra  cloth. 

DAY  (GEORGE  E.),  M.D.— A  PRACTICAL  TREATISE  ON  THE  DOMESTIC  MANAGEMENT  AND  MORE 
IMPORTANT  DISEASES  OF  ADVANCED  LIFE.  With  an  Appendix  on  a  new  and  successful  mode 
of  treating  Lumbago  and  other  forms  of  Chronic  Rheumatism.  One  volume  octavo,  226 
pages. 

ELLIS  (BENJAMIN),  M.D.— THE  MEDICAL  FORMULARY;  being  a  Collection  of  Prescriptions, 
derived  from  the  writings  and  practice  of  many  of  the  most  eminent  physicians  of  America 
and  Europe.  Together  with  the  usual  Dietetic  Preparations  and  Antidotes  for  Poisons. 
To  which  is  added  an  Appendix  on  the  Endermic  use  of  Medicines,  and  on  the  use  of  Ether 
and  Chloroform.  The  whole  accompanied  with  a  few  brief  Pharmaceutic  and  Medical 
Observations.  Tenth  edition,  revised  and  much  extended,  by  Robert  P.  Thomas,  M.D., 
Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one  neat  octavo 
volume  of  296  pages. 

ERICHSEN  (JOHN).— THE  SCIENCE  AND  ART  OF  SURGERY;  being  a  Treatise  on  Surgical  Inju- 
ries, Diseases,  and  Operations.  With  Notes  and  Additions  by  the  American  editor.  Illus- 
trated with  over  300  engravings  on  wood.  lu  one  large  and  handsome  octavo  volume  of 
nearly  900  closely  printed  pages. 

FLINT  (AUSTIN),  M.D. — PHYSICAL  EXPLORATION  AND  DIAGNOSIS  OP  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS.  In  one  handsome  octavo  volume,  extra  cloth,  of  636  pages.  (Nmo 
Beady.) 

FERGUSSON  (WILLIAM),  F.R.  S.— A  SYSTEM  OF  PRACTICAL  SURGERY.  Fourth  American,  from 
the  third  and  enlarged  London  edition.  In  one  large  and  beautifully  printed  octavo 
volume  of  about  700  pages,  with  393  handsome  illustrations. 


FRICK  (CHARLES),  M.D.— RENAL  AFFECTIONS  :  their  Diagnosis  and  Pathology.    With  illus- 
trations.   One  volume,  royal  12mo.,  extra  cloth. 


FOWNES  (GEORGE),  PH.  D.  —  ELEMENTARY  CHEMISTRY,  Theoretical  and  Practical.  With 
numerous  illustrations.  A  new  American,  from  the  last  and  revised  London  edition. 
Edited,  with  Additions,  by  Robert  Bridges,  M.  D.  In  one  large  royal  12mo.  volume,  of 
over  550  pages,  with  181  wood-cuts :  sheep,  or  extra  cloth.  (Now  Heady.) 


6  BLANCHARD  &  LEA'S  MEDICAL  PUBLICATIONS. 

GRAHAM  (THOMAS),  F.  R.  S.— THE  ELEMENTS  OF  CHEMISTRY.  Including  the  Application  of 
the  Science  to  the  Arts.  With  numerous  illustrations.  With  Notes  and  Additions,  by 
Robert  Bridges,  M.  D.,  etc.,  etc.  Second  American,  from  the  second  and  enlarged  London 
edition. 

PART  I.  (Lately  Issued)  large  8m,  430  pages,  185  illustrations. 

PART  H.  (Preparing)  to  match. 


GROSS  (SAMUEL  D.),  M.  D.— A  PRACTICAL  TREATISE  ON  THE  DISEASES,  INJURIES,  AND  MALFOR 

NATIONS  OF  THE  URINARY  BLADDER,  THE  PROSTATE  GLAND,  AND  THE  URETHRA.      Second  edition 

revised  and  much  enlarged,  with  184  illustrations.    In  one  very  large  and  handsome  octav< 
volume  of  over  900  pages,  extra  cloth  or  leather.    (Just  Issued.) 

(SAMUEL  D.),  M.  D. — A  PRACTICAL  TREATISE  ON  FOREIGN  BODIES  ra  THE  AIB-PASSAQE? 
n  one  handsome  octavo  volume,  with  illustrations. 


GROSS  (SAMUEL  D.),  M. D.— ELEMENTS  OF  PATHOLOGICAL  ANATOMY;  illustrated  by  colored 
engravings  and  250  wood-cuts.  Second  and  revised  edition.  In  one  large  imperial  octav* 
volume  of  822  pages,  leather. 

GROSS  (SAMUEL  D.),  M.D.— A  SYSTEM  OP  SURGERY;  Diagnostic,  Pathological,  Therapeutic, 
and  Operative.  With  very  numerous  engravings  on  wood.  (Preparing.) 

GLUGE  (GOTTLIEB),  M.D.— AN  ATLAS  OF  PATHOLOGICAL  HISTOLOGY.  Translated,  with  Notes 
and  Additions,  by  Joseph  Leidy,  M.  D.,  Professor  of  Anatomy  in  the  University  of  Penn- 
sylvania. In  one  volume,  very  large  imperial  quarto,  with  320  figures,  plain  and  colored, 
on  twelve  copper-plates. 

GRIFFITH  (ROBERT  E.),  M.D.— A  UNIVERSAL  FORMULARY,  containing  the  Methods  of  Pre- 
paring and  Administering  Officinal  and  other  Medicines.  The  whole  adapted  to  Physicians 
and  Pharmaceutists.  Second  edition,  thoroughly  revised,  with  numerous  Additions,  by 
Robert  P.  Thomas,  M.  D.,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Phar- 
macy. In  one  large  and  handsome  octavo  volume  of  over  600  pages,  double  columns. 


GRIFFITH  (ROBERT  E.).  M. D.— MEDICAL  BOTANY;  or,  a  Description  of  all  the  more  impor- 
tant Plants  used  in  Medicine,  and  of  their  Properties,  Uses,  and  Modes  of  Administration. 
In  one  large  octavo  volume  of  704  pages,  handsomely  printed,  with  nearly  350  illustrations 
on  wood. 


GARDNER  (D.  PEREIRA),  M.  D.— MEDICAL  CHEMISTRY,  for  the  use  of  Students  and  the  Pro- 
fession: being  a  Manual  of  the  Science,  with  its  Applications  to  Toxicology,  Physiology, 
Therapeutics,  Hygiene,  &c.  In  one  handsome  royal  12mo.  volume,  with  illustrations. 


HASSE  (C.  E.),  M.  D. — AN  ANATOMICAL  DESCRIPTION  OF  THE  DISEASFS  OF  RESPIRATION  AND  CIR- 
CULATION. Translated  and  edited  by  Swaine.  In  one  volume,  octavo. 

HARRISON  (JOHN),  M.  D.— AN  ESSAY  TOWARDS  A  CORRECT  THEORY  07  THE  NERVOUS  SYSTE:* 
In  one  octavo  volume,  292  pages. 

HUGHES  (H.  M.),  M.D.  — A  CLINICAL  INTRODUCTION  TO  THE  PRACTICE  OF  AUSCULTATION,  and 
other  Modes  of  Physical  Diagnosis,  in  Diseases  of  the  Lungs  and  Heart.  Second  American 
from  the  second  and  improved  London  edition.  In  one  royal  12mo.  volume.  (Jitst  Ready.} 

HORNER  (WILLIAM  E.%  M.  D.— SPECIAL  ANATOMY  AND  HISTOLOGY.  Eighth  edition.  Exten- 
sively revised  and  modified.  In  two  large  octavo  volumes,  of  more  than  1000  pages,  hand- 
somely printed,  with  over  300  illustrations. 

TIOBLYN  (RICHARD  D.),  A.  M.— A  DICTIONARY  OF  THE  TKRMS  U*TO  TN  MEDICINE  AND  THE  COT/- 
IATKRAL  SCIENCES.  Second  and  improved  American  edition.  Revised,  with  numerous  Ad- 
ditions, from  the  second  London  edition,  by  Isnae  Hays,  M.  D.,  &c.  In  one  large  royal 
12m o.  volume,  of  over  600  pages,  double  columns,  (Now  Ready.) 


BLANCHARD  &  LEA'S  MEDICAL  PUBLICATIONS.  T 

HAMILTON  (FRANK  II.) — A  TREATISE  ON  FRACTURES  AND  DISLOCATIONS.    In  one  handsome 
octavo  volume.    With  numerous  illustrations.    (Preparing.) 


HERSCIIEL  (SIR  JOHN  F.  W.),  F.  R.  S.— OUTLINES  OF  ASTRONOMY.  New  American,  from  the 
third  London  edition.  In  one  neat  volume,  crown  octavo,  with  six  plates  and  numerous 
wood-cuts. 


IIUMBOLDT  (ALEXANDER). — ASPECTS  OF  NATURE  IN  DIFFERENT  LANDS  AND  DIFFERENT  CLI- 
MATES.   Second  American  edition,  one  vol.  royal  12mo.,  extra  cloth. 


JONES  (T.  WII ARTON),  F.  R.  S. — THE  PRINCIPLES  AND  PRACTICE  OF  OPHTHALMIC  MEDICINE  AND 
SURGERY.  Second  American,  from  the  second  and  revised  English  edition.  With  Additions 
by  Edward  Hartshorne,  M.  D.  In  one  very  neat  volume,  large  royal  12mo,,  of  500  pages, 
with  110  illustrations. 


JONES  (C.  HANDFIELD),  F.R.S.,  AND  EDWARD  H.  SIEVEKING,  M.D.— A  MANUAL  op 
PATHOLOGICAL  ANATOMY.  With  397  engravings  on  wood.  In  one  handsome  volume,  octavo, 
of  nearly  750  pages,  leather.  (Lately  Issued.) 

KTRKES  (WILLIAM  SENIIOUSE),  M.D.,  AND  JAMES  PAGET,  F.R.S.— A  MANUAL  or  PHY- 
SIOLOGY. Second  American,  from  the  second  and  improved  London  edition.  With  165 
illustrations.  In  one  large  and  handsome  royal  12mo.  volume.  550  pages. 

KNAPP  (F.),  PH.  D.— TECHNOLOGY;  or,  Chemistry  applied  to  the  Arts  and  to  Manufactures. 
Edited,  with  numerous  Notes  and  Additions,  by  Dr.  Edmund  Ronalds  and  Dr.  Thomas 
Richardson.  First  American  edition,  with  Notes  and  Additions,  by  Professor  Walter  11. 
Johnson.  In  two  handsome  octavo  volumes,  printed  and  illustrated  in  the  highest  stylo 
of  art,  with  about  500  wood-engravings. 

LEHMANN  (G.  C.) — PHYSIOLOGICAL  CHEMISTRY.  Translated  from  the  .second  edition  by  George 
E.  Day,  M.D.  Edited  by  11.  E.  Rogers,  M.D.  With  illustrations  selected  from  Funke's 
Atlas  of  Physiological  Chemistry,  and  an  Appendix  of  Plates.  Complete  in  two  handsome 
octavo  volumes,  extra  cloth,  containing  1200  pages.  With  nearly  200  illustrations.  (Just 
Issued.) 

LETIMANN  (G.  C.) — MANUAL  OF  CHEMICAL  PHYSIOLOGY.  Translated  from  the  German,  with 
Notes  and  Additions,  by  J.  C.  Morris,  M.D.  With  an  introductory  Essay  on  Vital  Force, 
by  Samuel  Jackson,  M.  D.  In  one  handsome  octavo  volume,  extra  cloth,  of  336  pages. 
With  numerous  illustrations.  (Aow>  Heady.) 


LEE  (ROBERT),  M. D.— CLINICAL  MIDWIFERY;  comprising  the  Histories  of  Five  Hundred  and 

.  Forty-five  Cases  of  Difficult,  Preternatural,  and  Complicated  Labor,  with  Commentaries. 

From  the  second  London  edition.    In  one  royal  12mo.  volume,  extra  cloth,  of  238  pages. 


LA  ROCHE  (R.),  M.D. — PNEUMONIA;  its  Supposed  Connection,  Pathological  and  Etiological, 
with  Autumnal  Fevers,  including  an  Inquiry  into  the  Existence  and  Morbid  Agency  of 
Malaria.  In  one  handsome  octavo  volume,  extra  cloth,  of  500  pages. 


LA  ROCHE  (R.),  M.D.— YELLOW  FEVER,  considered  in  its  Historical,  Pathological,  Etiological, 
and  Therapeutical  Relations.  Including  a  Sketch  of  the  Disease  as  it  has  occurred  in 
Philadelphia  from  1699  to  1854,  with  an  Examination  of  the  Connections  between  it  and 
the  Fevers  known  under  the  same  name  in  other  Parts  of  Temperate,  as  well  as  in  Tropical 
Regions.  In  two  large  and  handsome  octavo  volumes,  of  nearly  1500  pages,  extra  cloth. 
(Just  Issued.) 

LAWRENCE  (W.).  F.  R.  S.— A  TREATISE  ON  DISEASES  OF  THE  EYE.  A  new  edition,  edited,  with 
numerous  Additions,  and  243  illustrations,  by  Isaac  Hays,  M.D..  Surgeon  to  Wills'  Hos 
pital,  etc.  In  one  very  large  and  handsome  octavo  volume  of  950  pages,  strongly  bound 
in  leather,  with  raised  bands. 


8  BLANCIIAKD  &  LEA'S  MEDICAL  PUBLICATIONS. 

LALLEMAND  (M.). — TUB  CAUSES,  SYMPTOMS,  AND  TREATMENT  OF  SPERMATORRHOEA.  Translated 
and  edited  by  Henry  J.  McDougal.  lu  one  volume,  octavo,  of  320  pages.  Second  Ame- 
rican edition. 


GARDNER  (DIONYSIUS),  D.C.L.— HANDBOOKS  OP  NATURAL  PHILOSOPHY  AND  ASTRONOMY. 
Revised,  with  numerous  Additions,  by  the  American  editor.  FIRST  COURSE,  containing 
Mechanics,  Hydrostatics,  Hydraulics,  Pneumatics,  Sound,  and  Optics.  In  one  large  royal 
12mo.  volume,  of  750  pages,  with  424  wood-cuts.  SECOND  COURSE,  containing  Heat,  Elec- 
tricity, Magnetism,  and  Galvanism,  one  volume,  large  royal  12mo.,  of  450  pages,  with  250 
illustrations.  THIRD  COURSE  (now  ready),  containing  Meteorology  and  Astronomy,  in  one 
large  volume,  royal  12mo.,  of  nearly  800  pages,  with  37  plates  and  200  wdod-cuts.  The 
whole  complete  in  three  volumes,  of  about  2000  largo  pages,  with  over  1000  figures  on  steel 
and  wood. 

MEIGS  (CHARLES  D.),  M.  D. — WOMAN:  HER  DISEASES  AND  THEIR  REMEDIES.  A  Series  of  Lec- 
tures to  his  Class.  Third  and  improved  edition.  In  one  large  and  beautifully-printed 
octavo  volume. 


MEIGS  (CHARLES  D.),  M. D.  —  OBSTETRICS:  THE  SCIENCE  AND  THE  ART.  Second  edition, 
revised  and  improved.  With  131  illustrations.  In  one  beautifully-printed  octavo  volume, 
of  752  large  pages. 


MEIGS  (CHARLES  D.),  M.D.  — A  TREATISE  ON  ACUTE  AND  CHRONIC  DISEASES  OF  THE  NECK  op 
THE  UTERUS.  With  numerous  plates,  drawn  and  colored  from  nature,  in  the  highest  style 
of  art.  In  one  handsome  octavo  volume,  extra  cloth. 


MEIGS  (CHARLES  D.),  M.  D.— OBSERVATIONS  ON  CERTAIN  OF  THE  DISEASES  OF  YOUNQ  CHILDREN. 
In  one  handsome  octavo  volume,  of  214  pages. 


MEIGS  (CHARLES  D.),  M.D.— ON  THE  NATURE,  SIGNS,  AND  TREATMENT  OP  CHILDBED  FEVER; 
in  a  Series  of  Letters  addressed  to  the  Students  of  his  Class.  In  one  handsome  octavo 
volume,  extra  cloth,  of  365  pages. 

MILLER  (JAMES),  F.  R.  S.  E.— PRINCIPLES  OF  SURGERY.  Fourth  American,  from  the  third  and 
revised  Edinburgh  edition.  In  one  large  and  very  beautiful  volume  of  700  pages,  with  240 
exquisite  illustrations  on  wood. 

MILLER  (JAMES),  F.R.S.E.— THE  PRACTICE  OF  SURGERY.  Third  American,  from  the  second 
Edinburgh  edition.  Edited,  with  Additions,  by  F.  W.  Sargent,  M.1X,  one  of  the  Surgeons 
to  Wills'  Hospital,  etc.  Illustrated  by  319  engravings  on  wood.  In  one  large  octavo 
volume  of  over  700  pages. 

MALGATGNE  (J.  F.).  —  OPERATIVE  SURGERY,  based  on  Normal  and  Pathological  Anatomy. 
Translated  from  the  French,  by  Frederick  Brittan,  A.  B.,  M.  D.  With  numerous  illustra- 
tions on  wood.  In  one  handsome  octavo  volume,  of  nearly  600  pages. 


MOHR  (FRANCIS),  PH.  D.,  AND  REDWOOD  (TIIEOPHILUS).— PRACTICAL  PHARMACY.  Com- 
prising the  Arrangements,  Apparatus,  and  Manipulations  of  the  Pharmaceutical  Shop 
and  Laboratory.  Edited,  with  extensive  Additions,  by  Prof.  William  Procter,  of  the  Phi- 
ladelphia College  of  Pharmacy.  In  one  handsomely-printed  octavo  volume,  of  570  pages, 
•with  over  500  engravings  on  wood. 

MACLISP  (JOSEPH).— SURGICAL  ANATOMY.  Forming  one  volume,  very  large  imperial  quarto. 
With  sixtv-eight  large  and  splendid  Plates,  drawn  in  the  best  style,  and  beautifully 
colored.  Containing  190  Figures,  many  of  them  the  size  of  life.  Together  with  copious 
and  explanatory  letter-press.  Strongly  and  handsomely  bound  in  extra  cloth,  being  one 
of  the  cheapest  and  best  executed  Surgical  works  as  yet  issued  in  this  country. 
Copies  can  be  sent  by  mail,  in  five-  parts,  done  up  in  etout  covers. 


BLANCHARD  &  LEA'S  MEDICAL  PUBLICATIONS.  9 

MAYNE  (JOHN),  M.D. — A  DISPENSATORY  AND  THERAPEUTICAL  REMEMBRANCER.  Comprising 
the  entire  lists  of  Materia  Medica.  with  every  Practical  Formula  contained  in  the  thre& 
British  Pharmacopoeias.  In  one  12mo.  volume,  extra  cloth,  of  over  300  large  pages. 

MACKENZIE  (W.),  M.D.— A  PRACTICAL  TREATISE  ON  DISEASES  AND  INJURIES  OF  THE  Era  To 
which  is  prefixed  an  Anatomical  Introduction,  by  T.  Wharton  Jones.  From  the  fourth 
revised  and  enlarged  London  edition.  With  Notes  and  Additions  by  Addinell  Hewson, 
M.D.  In  one  very  large  and  handsome  octavo  volume,  with,  numerous  wood-cuts  and 
plates.  1028  pages,  leather,  raised  bands.  (Just  Issued.') 

NEILL  (JOHN),  M.D.,  AND  FRANCIS  GURNEY  SMITH,  M.D.— AN  ANALYTICAL  COMPENDIUM 

OP  THE  VARIOUS  BRANCHES  OF  MEDICAL  SCIENCE;  for  the  Use  and  Examination  of  Students. 

J|     Second  edition,  revised  and  improved.    In  one  very  large  and  handsomely  printed  royal 

12mo.  volume  of  over  1000  pages,  with  350  illustrations  on  wood.    Strongly  bound  iu 

leather,  with,  raised  bands. 

NEILL  (JOHN),  M.D. — OUTLINES  OF  THE  ARTERIES.    1  vol.  8vo.,  handsome  colored  plates. 

OUTLINES  OF  THE  NERVES.    1  vol.  8vo.,  with  handsome  plates.    OUTLINES  OF  THE  VEINS  AND 

LYMPHATICS,  1  vol.  8vo.,  handsome  colored  plates. 
Also,  the  three  works  done  up  in  one  handsome  volume,  half  bound.         , 

NELIGAN  (J.  MOORE),  M.D.  — ATLAS  OF  CUTANEOUS  DISEASES.  In  one  beautiful  qxiarto 
volume,  extra  cloth,  with  splendid  colored  plates,  presenting  nearly  one  hundred  elaborate 
representations  of  disease.  (Now  Heady.) 

NELIGAN  (J.  MOORE),  M.  D.— A  PRACTICAL  TREATISE  ON  DISEASES  OP  THE  SKIN.  In  one  neat 
royal  12mo.  volume,  of  334  pages. 

OWEN  (PROP.  R.)— ON  THE  DIFFERENT  FORMS  OF  THE  SKELETON.  One  royal  12mo.  volume, 
with  numerous  illustrations. 


PANCOAST  (J.),  M.D. — OPERATIVE  SURGERY;  or,  A  Description  and  Demonstration  of  the 
various  Processes  of  the  Art;  including  all  the  New  Operations,  and  exhibiting  the  state 
of  Surgical  Science  in  its  present  advanced  condition.  Complete  in  one  royal  4to.  volume 
of  380  pages  of  letterpress  description  and  eighty  large  4to.  plates,  comprising  486  illus- 
trations. Second  edition,  unproved. 

PARKER  (LANGSTON).— THE  MODERN  TREATMENT  OF  SYPHILITIC  DISEASES,  BOTH  PRIMARY  AND 
SECONDARY:  comprising  the  Treatment  of  Constitutional  and  Confirmed  Syphilis,  by  a  safe 
and  successful  method.  With  numerous  Cases,  Formulae,  and  Clinical  Observations. 
From  the  third  and  entirely  rewritten  London  edition.  In  one  neat  octavo  volume. 


PEREIRA  (JONATHAN),  M.D.— THE  ELEMENTS  OF  MATERIA  MEDICA;AND  THERAPEUTICS.  Third 
American  edition,  enlarged  and  improved  by  the  author;  including  Notices  of  most  of  the 
Medical  Substances  in  use  in  the  civilized  world,  and  forming  an  Encyclopaedia  of  Materia 
Medica.  Edited,  with  Additions,  by  Joseph  Carson,  M.  D.,  Professor  of  Materia  Medica  and 
Pharmacy  in  the  University  of  Pennsylvania.  In  two  very  large  octavo  volumes  of  2100 
pages,  on  small  type,  with  over  450  illustrations.  (Now  Complete.) 


PARRISII  (EDWARD).— AN  INTRODUCTION  TO  PRACTICAL  PHARMACY.  Designed  as  a  Text-book 
for  the  Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With  many  For- 
miilfB  and  Prescriptions.  In  one  handsome  octavo  volume,  extra  cloth,  of  550  pages, 
with  243  illustrations.  (Now  Ready.) 


PEASELEE  (E.  R.),  M.  D.— HUMAN  HISTOLOGY,  in  its  Applications  to  Physiology  and  General 
Pathology,  designed  as  a  Text-book  for  Medical  Students.  With  numerous  illustrations. 
In  one  handsome  royal  12mo.  volume.  (Preparing.) 


PIRRTE  (WILLIAM),  F.  R.  S.  E.— THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.  Edited  by  John 
Neil],  M.D..  Detaonstrator  of  Anatomy  in  the  University  of  Pennsylvania,  Surgeon  to  the 
Pennsylvania  Hospital,  etc.  In  one  very  handsome  octavo  volume  of  780  pages,  with  316 
illustrations. 

RAMSBOTHAM  (FRANCIS  II.),  M.D.— THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDICINE 
AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged  edition, 
thoroughly  revised  by  the  author.  With  Additions,  by  W.  V.  Keating,  M.D.  In  one  lanre 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  raised 
bands.  With  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  text,  containing 
in  all  nearly  200  large  and  beautiful  figures.  (Just  Issued.) 


10  BLANCHARD  &  LEA'S  MEDICAL  PUBLICATIONS. 

RICORD  (P.),  M.D. — ILLUSTRATIONS  OF  SYPHILITIC  DISEASE.  Translated  from  the  French,  by 
Thomas  F.  Betton,  M.  D.  With  the  addition  of  a  History  of  Syphilis,  and  a  complete  Bibli 
o^raphy  and  Formulary  of  Remedies,  collated  and  arranged  by  Paul  B.  Goddard,  M.D. 
With  fifty  large  quarto  plates,  comprising  117  beautifully  colored  illustrations.  In  one 
large  and  handsome  quarto  volume. 

RICORD  (P.),  M.  D.— A  TREATISE  ON  THE  VENEREAL  DISEASE.  By  John  Hunter,  F.  R.  S.  With 
copious  Additions,  by  Ph.  Ricord,  M.D.  Edited,  with  Notes,  by  Freeman  J.  Bumstead, 
M.  D.  In  one  handsome  octavo  volume,  with  plates. 


RICORD  (P.),  M.  D.— LETTERS  ON  SYPHILIS,  addressed  to  the  Chief  Editor  of  the  Union  Metli- 
cale.  With  an  Introduction,  by  Amedee  Latour.  Translated  by  W.  P.  Lattimore,  M.D. 
In  one  neat  octavo  volume. 

ROKITANSKY  (CARL).— A  MANUAL  OP  PATHOLOGICAL  ANATOMT.  Translated  from  the  Ger- 
man by  VV.  E.  Swaine,  Edward  Sieveking,  M.D.,  C.  H.  Moore,  and  George  E.  Day,  M.D. 
Complete,  four  volumes  bound  in  two,  extra  cloth,  of  about  1200  pages.  (Just  Issued.) 

RIGBY  (EDWARD),  M.D.— A  SYSTEM  OP  MIDWIFERY.  With  Notes  and  Additional  Illustra- 
tions. Second  American  edition.  One  volume  octavo,  422  pages. 


ROYLE  (J.  FORBES),  M.D.— MATERIA  MEDICA  AND  THERAPEUTICS;  including  the  Preparations 
of  the  Pharmacopoeias  of  London,  Edinburgh,  Dublin,  and  of  the  United  States.  With 
many  new  Medicines.  Edited  by  Joseph  Carson,  M.D.,  Professor  of  Materia  Medica  and 
Pharmacy  in  the  University  of  Pennsylvania.  WTith  ninety-eight  illustrations.  In  one 
large  octavo  volume  of  about  700  pages. 


SKEY  (FREDERICK  C.),  F.  R.  S.— OPERATIVE  SURGERY.  In  one  very  handsome  octavo  volume 
of  over  650  pages,  with  about  100  wood-cuts. 

SHARPEY  (WILLIAM),  M.D.,  JONES  QUAIN,  M.D.,  AND  RICHARD  QUAIN,  F.R.  S.,  etc.— 
HUMAN  ANATOMY.  Revised,  with  Notes  and  Additions,  by  Joseph  Leidy,  M.D.  Complete 
in  two  large  octavo  volumes,  of  about  1300  pages.  Beautifully  illustrated  with  over  500 
engravings  on  wood. 

SMITH  (HENRY  H.),  M.  D.,  AND  WILLIAM  E.  HORNER,  M.  D.— AN  ANATOMICAL  ATLAS 
illustrative  of  the  Structure  of  the  Human  Body.  In  one  volume,  large  imperial  octavo, 
with  about  660  beautiful  figures. 


SMITH  (HENRY  H.),  M.D.— MINOR  SURGERY;  or,  Hints  on  the  Every-day  Duties  of  the 
Surgeon.  With  247  illustrations.  Third  and  enlarged  edition.  In  one  handsome  royal 
12mo.  volume  of  456  pages 

SARGENT  (F.  W.),  M.D.— ON  BANDAGING  AND  OTHER  OPERATIONS  OP  MINOR  SURGERY.  Second 
edition,  enlarged.  In  one  handsome  royal  12mo.  volume  of  nearly  400  pages,  with  182 
illustrations.  (Just  Issued.) 

STILLS  (ALFRED),  M.  D.— PRINCIPLES  OF  THERAPEUTICS.  In  one  handsome  volume,  pre- 
paring.) 

SIMON  (JOHN),  F.  R.  S. — GENERAL  PATHOLOGY,  as  conducive  to  the  Establishment  of  Rational 
Principles  for  the  Prevention  and  Cure  of  Disease.  A  Course  of  Lectures  delivered  at  St. 
Thomas's  Hospital  during  the  Summer  Session  of  1850.  In  one  neat  octavo  volume. 


SMITH  (W.  TYLER),  M.  D.— ON  PARTURITION,  AND  THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS, 
In  one  large  duodecimo  volume  of  400  pages. 


SMITH  (W.  TYLER),  M.D. — THE  PATHOLOGY  AND  TREATMENT  OF  LEUCORRHOIA.    With  nume- 
rous illustrations.    In  one  very  handsome  octavo  volume,  extra  cloth,  of  about  250  pages. 


BLANCIIARD  &  LEA'S  MEDICAL  PUBLICATIONS.  11 

SOLLY  (SAMUEL),  F.R.S.  — THE  HUMAN  BRAIN;  its  Structure,  Physiology,  and  Diseases. 
"With  a  Description  of  the  Typical  Forms  of  the  Brain  in  the  Animal  Kingdom.  From  the 
Second  and  much  enlarged  London  edition.  In  one  octavo  volume,  with  120  wood-cuts. 


SCHCEDLER  (FRIEDRICII),  PH.  D. — THE  BOOK  OF  NATURE;  an  Elementary  Introduction  to 
the  Sciences  of  Physics,  Astronomy,  Chemistry,  Mineralogy,  Geology,  Botany,  Zoology,  and 
Physiology.  First  American  edition,  with  a  Glossary  and  other  Additions  and  Improve- 
ments; from  the  second  English,  edition.  Translated  fron*  the  sixth  German  edition,  by 
Henry  Medlock,  F.C.S.,  &c.  In  one  thick  volume,  small  octavo,  of  ahout  700  pages,  -with 
679  illustrations  on  wood.  Suitable  for  the  higher  schools  and  private  students.  (JVow 
£eady.) 

TAYLOR  (ALFRED  S.),  M.D.,  F.R.  S. — MEDICAL  JURISPRUDENCE.  Fourth  American,  from  the 
fifth  and  improved  English  edition.  With  Notes  and  References  to  American  Decisions, 
by  Edward  Hartshorne,  M.  D.  In  one  large  octavo  volume  of  700  pages.  (Now  Heady.) 


TAYLOR  (ALFRED  S.),  M.  D.— ON  POISONS,  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND  MEDI- 
CINE. Edited,  with  Notes  and  Additions,  by  R.  E.  Griffith,  M.D.  In  one  large  octavo 
volume  of  688  pages. 

TANNER  (T.  H.),  M.  D.— A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAGNOSIS.  To  which 
is  added,  The  Code  of  Ethics  of  the  American  Medical  Association.  In  one  neat  volume, 
small  12mo.,  extra  cloth,  or  flexible.  (Just  Issued.) 


TOMES  (JOHN),  F.R.S.— A  MANUAL  OF  DENTAL  PRACTICE.   Illustrated  by  numerous  engravings 
on  wood.    In  one  handsome  volume.    (Preparing.) 


TODD  (R.  B.),  M.D.,  AND  WILLIAM  BOWMAN,  F.R.S. — PHYSIOLOGICAL  ANATOMY  AND  PHYSI- 
OLOGY OF  MAN.    With  numerous  handsome  wood-cuts.    Parts  I.,  II.,  and  III.,  in  one  octavo 
volume,  552  pages.    Part  IV.  will  complete  the  work. 
I 

WATSON  (THOMAS),  M.  D.,  &c.  —  LECTURES  ON  THE  PRINCIPLES  AND  PRACTICE  OF  PHYSIC. 
Third  American,  from  the  last  London  edition.  Revised,  with  Additions,  by  D.  Francis 
Condie,  M.D.,  author  of  a  "Treatise  on  the  Diseases  of  Children."  &c.  In  one  octavo 
volume,  of  nearly  1100  large  pages,  strongly  bound,  with  raised  bands. 


WALSIIE  (W.  H.),  M.D. — DISEASES  OF  THE  HEART,  LUNGS,  AND  APPENDAGES;  their  Symptoms 
and  Treatment.    In  one  handsome  volume,  large  royal  12mo.,  512  pages. 


WHAT  TO  OBSERVE  AT  THE  BEDSIDE  AND  AFTER  DEATH,  IN  MEDICAL  CASES.  Published  under  the 
authority  of  the  London  Society  for  Medical  Observation.  In  one  very  handsome  volume, 
royal  12ino.,  extra  cloth. 


WILDE  (W.  R.). — AURAL  SURGERY,  AND  THE  NATURE  AND  TREATMENT  OF  DISEASES  OF  THE  EAR. 
In  one  handsome  octavo  volume,  with  illustrations. 


WIIITEHEAD  (JAMES),  F.  R.  C.  S.,  &c.  —  THE  CAUSES  AND  TREATMENT  OF  ABORTION  AND  STE- 
RILITY; being  the  Result  of  an  Extended  Practical  Inquiry  into  the  Physiological  and 
Morbid  Conditions  of  the  Uterus.  Second  American  Edition.  In  one  volume,  octavo,  368 


WEST  (CHARLES),  M.D.— LECTURES  ON  THE  DISEASES  OF  INFANCY  AND  CHILDHOOD.    Second 
American,  from  the  second  and  enlarged  London  edition.    In  one  volume,  octavo,  of  nearly 

500  pages. 


12  BLANCHARD  &  LEA'S  MEDICAL  PUBLICATIONS. 

WEST  (CHARLES),  M.  D.— AN  INQUIRY  INTO  THE  PATHOLOGICAL  IMPORTANCE  OF  ULCERATION  OF 
THE  Os  UTERI.  Being  the  Croonian  Lectures  for  the  year  1854.  In  one  neat  octavo  volume, 
extra  cloth. 

WEST  (CHARLES),  M.  D.— LECTURES  ON  TEE  DISEASES  OF  WOMEN.  In  two  Parts.  Part  I, 
Diseases  of  the  Uterus:  Part  II,  Diseases  of  ihe  Ovaries,  etc.,  the  Bladder,  Vagina,  and 
External  Organs. 

***  Publishing  in  the  "  MEDICAL  NEWS  AND  LIBRARY"  for  1856  and  1857. 

WILSON  (ERASMUS),  M.D..  F.R.S.— A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special. 
Fourth  American,  from  the  last  English  edition.  Edited  by  Paul  B.  Goddard,  A.M.,  M.D. 
With  250  illustrations.  Beautifully  printed,  in  one  large  octavo  volume,  of  nearly  600 

pages. 

WILSON  (ERASMUS),  M.D.,  F.R.S.— THE  DISSECTOR'S  MANUAL;  Practical  and  Surgical  Ana- 
tomy. Third  American,  from  the  last  revised  and  enlarged  English  edition.  Modified  and 
rearranged  by  William  Hunt,  M.D.  In  one  large  and  handsome  royal  12ioo.  volume, 
leather,  of  582  pages,  with  154  illustrations.  (Now  Ready.} 

WILSON  (ERASMUS),  M.D.,  F.  R.  S.— ON  DISEASES  OF  THE  SKIN.  Third  American,  from,  the 
third  London  edition.  In  one  neat  octavo  volume,  of  about  500  pages,  extra  cloth. 


WILSON  (ERASMUS),  M.D.,  F.R.S.  —  ON  CONSTITUTIONAL  AND  HEREDITARY  SYPHILIS.  AND  ON 
SYPHILITIC  ERUPTIONS.  In  one  small  octavo  volume,  beautifully  printed,  with  four  exqui- 
site colored  plates,  presenting  more  than  thirty  varieties  of  Syphilitic  Eruptions. 


WILSON  (ERASMUS),  M.  p..  F.R.  S.— HEALTHY  SKIN;  a  Treatise  on  the  Management  of  the 
Skin  and  Hair  in  Relation  to  Health.  Second  American,  from  the  fourth  and  improved 
London  edition.  In  one  handsome  royal  12mo.  volume,  extra  cloth,  with  numerous  illus- 
trations. Copies  may  also  be  had  in  paper  covers,  for  mailing,  price  75  cents.  (Now  Ready.) 


WILLIAMS  (C.  J.  B.),  M.D.,  F.R.S.— PRINCIPLES  OF  MEDICINE;  comprising  General  Pathology 
and  Therapeutics,  and  a  brief  general  view  of  Etiology,  Nosology,  Semeiology,  Diagnosis, 
Prognosis,  and  Hygienics.  Edited,  with  Additions,  by  Meredith  Clymer,  M.D.  Fourth 
American,  from  the  last  and  enlarged  London  edition.  In  one  octavo  volume,  of  476  pages. 


WILLIAMS  (C.  J.  B.).  M.  D.,  F.R.S. — A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  RESPIRATORY 
ORGANS;  including  Diseases  of  the  Larynx,  Trachea.  Lungs,  and  Pleuras.  With  numerous 
Additions  and  Notes,  by  M.  Clymer,  M.D.  With  wood-cuts.  In  one  octavo  volume,  pp.  508. 


YOUATT  (WILLIAM),  V.S.  — THE  HORSE.  A  new  edition,  with  numerous  illustrations; 
together  with  a  General  History  of  the  Horse;  a  Dissertation  on  the  American  Trotting 
Horse;  how  Trained  and  Jockeyed;  an  Account  of  his  Remarkable  Performances;  and  an 
Essay  on  the  Ass  and  the  Mule.  By  J.  S.  Skinner,  formerly  Assistant  Postmaster-General, 
and  Editor  of  the  Turf  Register.  One  large  octavo  volume. 


YOU  ATT  (WILLIAM),  V.  S.— THE  DOG.    Edited  by  E.  J.  Lewis,  M.D.    With  numerous  and 
beautiful  illustrations.    In  one  very  handsome  volume,  crown  Svo.,  crimson  cloth,  gilt. 


Blanchard  &  Lea  have  now  ready  a  detailed  Catalogue  of  their  publications,  in  Medical  nnd 
other  Sciences,  with  Specimens  of  the  Wood-engravings,  Notices  of  the  Press,  &c.  Ac.,  forming 
a  pamphlet  of  sixty-four  large  octavo  pages.  It  has  been  prepared  without  regard  to  expense, 
and  may  be  considered  as  one  of  the  handsomest  specimens  of  printing  as  yet  executed  in 
this  country.  Copies  will  be  sent  free,  by  post,  on  receipt  of  two  three-cent  postage  stamps. 

Detailed  Catalogues  of  their  publications,  Miscellaneous,  Educational,  Medical,  ic.,  fur- 
nished gratis,  on  application. 


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